Care Manager of Health Home Care Management

Essential Duties And 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.
• 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.
• Reaches out to patients to help them keep scheduled appointments; arranges for appropriate metabolic and periodic preventive screening in accordance with agency policy.
• Facilitates discussions between the patient and physician as necessary to ensure patients are aware of test results.
• Collaborates with the extended care team providers to ensure that integrated care plan is fully implemented.
• Regularly reviews workload report in TREAT to identify patients requiring assessments outreach and engagement.
• 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.

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