Job Openings

PROGRAM DESCRIPTION

Care Management is a service model whereby all of an individual's caregivers communicate so that the patient's needs are addressed in a comprehensive manner. This is done primarily through a "care manager" who oversees and provides access to all of the services an individual’s needs to assure that they receive everything necessary to prevent hospitalizations, stay healthy, and maintain stability. The Health home program is a voluntary program for all community members of NYC who have multiple chronic conditions and/or mental diagnosis who need a care manager to help them with a social and a medical need.

The Care Manager guides program enrollees and their caretakers (legal guardians) through the health care system by assisting with access issues, developing relationships with service providers, providing education and tracking interventions/outcomes.

MAJOR DUTIES & RESPONSIBILITIES:

• Explaining and ensuring the understanding of the health home program and core services to all members. Assist in obtaining the required documentation from members including enrollment consents and care plans signed by the individual or legal guardian as needed.
• Completing detailed documentation in the RMA software on all communications with members, family support members and multidisciplinary team.
• Providing core services to special populations such as HARP/High Risk High Need members, complete required documents needed for enrollment such as UAS Eligibility assessments, coordinating with MCO’s, HARP CM’s & completion of workflow for coordinating with HCBS services as needed.
• Completes initial and ongoing needs assessments to determine the individual’s most appropriate level of care management.
• Identify the member’s needs and goals and include family members and other social supports as appropriate and provide core services to assist members.
• Complete a comprehensive health assessment and annual reassessments inclusive of medical, behavioral, rehabilitative and long-term care and social service needs.
• Create a patient-centered/ evidence-based care plan to assist member with their goals for wellness and update the care plan every bi-annually and as needed.
• Provides core services to member using creative techniques, evidence-based practices, and motivational interviewing strategies to assist members to reach their goals leading towards graduation. Practices should assist member with behavioral changes that leads to reduced ER visits and longevity in optimal health decisions.
• Consult with members multidisciplinary team (primary care physician & specialists) on a quarterly basis that correspond to the members care Plan, needs and goals including sharing the care crisis intervention and emergency info as needed.
• Conduct member outreach and engagement activities linked to core services to assess ongoing needs, promote continuity of care and improve health outcomes.
• Identify, linking, advocating and/or referring members to needed community services to support care plan and treatment goals, including medical/behavioral health care, patient education and self-help/recovery and self-management.
• Monitoring, supporting or accompanying the member to scheduled medical appointments or social services as needed.
• Following up with hospital, ER, & family members upon notification of a member's admission and/or discharge. Facilitating discharge planning from ER, hospital, residential or rehabilitative setting to ensure a safe transition/discharge where care needs are in place.
• Responsible for the overall management of the patient’s Individualized Plan of Care and activities with the member that leads to the members graduation of the program.
• Ability to receive transferred cases, check for discrepancies and follow up with cases as needed to ensure compliance with program requirements.
• Conduct self-audits and/or peer review audits monthly.
• Participate and provide input alongside Quality improvement activities and meetings with the Quality improvement team.
• Participate in Bi-Weekly individual Supervision, monthly training and case round.
• Attends and participates in ongoing staff development trainings to enhance skills as needed to effectively meet the demands of the Care Manager position.
• All other duties, as needed, by ACCM.

• Care Managers serving adults will be required to have face-face visits at least once every 6 months per member to sign Care plans in person and on a consistent schedule as per the mandates of their acuity level (high, medium, or low).
• Meets Care Management documentation requirements in a timely and accurate manner.
• Help members obtain and maintain public benefits necessary to gain health care services, including Medicaid and cash assistance eligibility, Social Security, SNAP, housing, legal services, employment and training supports.
• Effectively communicates and shares information with the individual, their families or other care givers and multidisciplinary team members where authorization is provided by the member to effectively provide/coordinate comprehensive and holistic care that leads the members towards successful graduation, reduction of ER visits and improvement in the quality of life of the member
• Provide culturally competent services based on language, literacy socioeconomic status and cultural preferences of the member as needed.

Other Requirements:

• While performing the responsibilities of the job, the employee is required to occasionally move about inside the office to access file cabinets, office machinery, operate a computer and other office productivity machinery (i.e., a calculator, copy machine, and computer printer) etc.
• Adhere to telecommuting and remote work policies.
• Employee is required to frequently communicate with members/employees/Supervisors who have inquiries about services that you are providing. Must be able to communicate and exchange accurate information in these situations in a timely manner.

QUALIFICATIONS & COMPETENCIES:

Education and Experience Required:

• A Bachelors of Arts or Science with relevant experience, providing care coordination, education and/or referrals for NYC community-based services for adults with chronic disease and/or mental diagnosis needs.
• Knowledge of disease management and social services in NYC and special populations.
• Solid organizational and follow-up skills
• Computer Literacy and Tech Savy –learn and adapt to different IT platforms
• Excellent interpersonal skills and clear direct communication with others (oral and written)
• Ability to manage and work with a variety of different people and independently
• Flexibility to travel throughout NYC
• Bi-lingual preferred (Chinese/ Spanish)