Care Manager of Health Home Care Management

About the role

Sun River Health provides comprehensive primary, preventative, and behavioral health services to all patients, prioritizing those with limited resources and facing social challenges. We are a Federally Qualified, Non-Profit Health Center serving communities in multiple counties across New York State.

Responsibilities

• Works closely with the interdisciplinary care team including the PCP, mental health provider, residential services, substance abuse provider, etc. in the development and ongoing coordination of the care plan.
• Works closely with the Patient Navigator to direct field activity as needed and ensure the flow of information across and between the care team is optimized.
• Provides input to providers/patient/family for written individualized care plans.
• Reviews patient intake assessments and uses results to coordinate the completion of the care plan, self-management goals and strategies.
• In conjunction with the patient, identifies potential barriers to care and helps patient identify ways to overcome those barriers; reaches out to patients who have not met treatment goals to resolve barriers/adjust goals when possible.
• Evaluates medication compliance and assesses potential barriers to adherence; ensures medication reconciliation is current.
• Receives alerts to inpatient and ER admissions. Visits patients during inpatient stays and participates actively in discharge planning and care transition activities. Contacts patients after discharge from inpatient services and ER within one business day.
• Contacts patients to help them keep scheduled appointments; arranges for appropriate metabolic and periodic preventive screenings in accordance with agency policy.
• Ensures that patients and caregivers are aware of test results by facilitating discussions between the patient and physician as necessary.
• Collaborates with the extended care team providers to ensure that the integrated care plan is fully implemented.
• Regularly reviews workload report in TREAT to identify patients requiring assessments, outreach, and engagement.
• Provides or arranges for provision of self-management/wellness education, peer and other support groups in the language preferred by the patient/family.
• Organizes and participates in case conferences as per patient need and in accordance with agency policy.
• Reviews benefits, entitlements, housing with the patient/family and assists in the application process. Follows up as necessary to ensure services are approved.
• Utilizes the TREAT system to complete all documentation and assessments timely including scheduling of all activity.

Requirements

• Minimum Education Requirement: High School diploma/GED
• Preferred Education Requirement: Bachelor’s degree in Health or Human Services related field
• Minimum Work Related Experience: 2 years

Qualifications

• Strong interpersonal skills and the ability to communicate effectively with patients, families, and healthcare providers.
• Excellent organizational and time management skills.
• Ability to prioritize tasks and manage multiple projects simultaneously.
• Proficiency in Microsoft Office Suite.
• Knowledge of electronic health record systems.

Skills

• Strong communication and collaboration skills.
• Ability to work independently and as part of a team.
• Effective problem-solving and decision-making abilities.
• Strong attention to detail and accuracy.

Benefits

At Sun River Health, we offer competitive compensation and benefits packages, including:

• Health insurance coverage
• Paid time off
• Professional development opportunities
• Flexible schedule options

Pay

$23.00 - $25.80 per hour

Schedule

Full-time position