Care Manager of Health Home Care Management

Sun River Health provides the highest quality of comprehensive primary, preventative and behavioral health services to all who see it, regardless of insurance status and ability to pay, especially for the underserved and vulnerable. Sun River Health is a Federally Qualified, Non-Profit Health Center serving communities in Suffolk, Rockland, Orange, Dutchess, Ulster, Sullivan, Columbia and Westchester County. Sun River Health is currently seeking a full-time Care Manager to join our team at the Church Avenue Health Home site located in Brooklyn, NY. 

The Health Home Care Manager provides care coordination and support to clients with chronic medical and behavioral health conditions that are also impacted by social determinants of health. Assists clients navigate social service, community, and healthcare systems.

*$1,500 sign-on bonus. Terms and conditions apply*

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.

• 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.

• Reaches out to patients to help them keep scheduled appointment; arranges for appropriate metabolic and periodic preventive screening in accordance with agency policy.

• Ensures that patients and care givers are aware of test results by facilitating discussions between the patient and physician as necessary.

• 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.

• Provides or arranges for provision of self-management/ wellness education, peer and other support groups in the language that the patient/family prefers.

• 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

Job Type: Full-time

Hourly rate: $23.00 - $26.37 per hour

Relation to Mission
The mission of Sun River Health is to increase access to comprehensive primary and preventive health care and to improve the health status of our community, especially for the underserved and vulnerable.

Equal Employment Opportunity
Sun River Health provides equal employment opportunities to all qualified individuals without regard to race, creed, color, religion, national origin, age, sex, marital status, sexual preference, or non-disqualifying physical or mental handicap or disability in each aspect of the human resources function.

Americans with Disabilities Act
Applicants as well as employees who are or become disabled must be able to perform the essential job functions either unaided or with reasonable accommodation. The organization shall determine reasonable accommodation on a case-by-case basis in accordance with applicable law.

Job Responsibilities
The following statements reflect the general duties, responsibilities and competencies considered necessary to perform the essential functions of the job and should not be considered as a detailed description of all the work requirements of the position. Sun River Health may change the specific job duties with or without prior notice based on the needs of the organization.