Department & Position Overview: 

The Health Home Care Manager will work to outreach and engage potentially eligible patients and obtain appropriate consents to enroll the patient in the Health Home Care Management Program. Once the patient is enrolled, the Health Home Care Manager will work collaboratively with the patient's care team to complete a comprehensive assessment and patient centered care plan, and to coordinate care based on the care plan. 

Every Day You Will:

• Screen for Health Home functional scale eligibility, conduct initial Health Homes assessments and reassessments of patient needs, including medical, mental health, substance use, financial, housing, and additional support needs
• Collaborate with the medical providers and patients to develop, implement, and coordinate Health Homes compliant care plans for patients with chronic diseases, such as diabetes, asthma, congestive heart failure, hypertension, mental health conditions, substance use, and more and document care plan outcomes
• Provide direct service to a caseload of chronically ill patients and help them achieve their care plan goals by facilitating referrals, addressing access issues, connecting them to local resources, and developing relationships with healthcare providers
• Coordinate patient services and care with pharmacies, insurance companies, hospital discharge planning, family caregivers, and other providers
• Provide crisis intervention when needed
• Conduct home visits and maintain patient contact and documentation of all services in accordance with Health Homes standards
• Maintain patient confidentiality at all times

Ideal Candidate Will Possess:

• Associate's degree is a must
• 2 years of Care Management experience
• Must be able to travel to minimum of 2 boroughs - Bronx and Manhattan
• Ability to travel in the field to accompany patients to appointments and meet patients in person when needed
• Strong working knowledge of local community resources
• Demonstrated ability to work with data reporting, documentation, and outcomes
• Strong communication and assessment skills; the ability to relate to patients, their families, and community care providers, along with ability to handle rapidly changing crisis situations
• Ability to manage high volume caseloads
• Able to express empathy and compassion for the underserved
• Experience navigating several data management systems, such as Salesforce

Nice-to-Haves:

• Bachelor's Degree is a plus
• Bilingual Spanish strongly preferred
• Access to a vehicle is strongly preferred