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Care Manager

Family Services Network Of New York • Full-time • Brooklyn, New York • 6d ago

Job Details

Experienced

1420 Bushwick - Brooklyn, NY

N/A

Full Time

Bachelors

Undisclosed

Day

Nonprofit - Social Services

Job Description

The Health Home Care Manager is required to have a detailed understanding of the health focused work and is primarily responsible for assessments, service plan development, case coordination, linking and advocacy; monitoring, and clinical consultation. Their focus is on coordinating and arranging for the provision of services; supporting adherence to treatment recommendations; and monitoring and evaluating a member’s needs, including prevention, wellness, medical, specialist and behavioral health treatment, care transitions, and social and community services where appropriate through the creation of an individual plan of care. The Care Manager is expected to use an individualized care service delivery approach ensuring the services are designed to address the unique needs and strengths of each member.

Job Responsibilities

Essential Job Functions:

Provide the core services for health home management for all members on their caseload in conjunction with acuity. 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 Care 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 reports in GSI (client database/proprietary software) 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 GSI system to complete all documentation and assessments timely including scheduling of all activity.