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 who are uninsured or underinsured. 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.
• Closely works 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 patients 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.
• Helps patients keep scheduled appointments; arranges for appropriate metabolic and periodic preventive screenings in accordance with agency policy.
• Facilitates discussions between the patient and physician regarding test results.
• Coordinates services between patient and 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.

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 and communication skills
• Ability to work independently and as part of a team
• Excellent organizational and time management skills
• Proficiency in Microsoft Office Suite

Skills

• Medication management
• Discharge planning
• Case management
• Interdisciplinary collaboration
• Communication with patients and families

Benefits

Not specified

Pay

$23.00 - $26.37 per hour

Schedule

Full-time