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About the Role

The Health Home Care Manager (HHCM) guides chronically ill patients through the healthcare system, assisting with access issues, developing relationships with service providers, and tracking interventions and outcomes. This role acts as a team leader, providing direct patient services including needs assessments, developing care plans, and coordinating comprehensive services. The HHCM also advocates for clients within the agency and with external providers, ensuring overall service provision and coordination for assigned patients.

Responsibilities

• Provides direct service to a caseload of approximately 60 patients.
• Provide patient and family support by way of linkage to community resources.
• Conducts and documents initial assessments of patients’ needs including medical, mental health, substance use and social determinants of health within 60 days of enrollment.
• Provides crisis intervention and health education services as needed.
• Develops individualized patient centered plan of care with documented input and approval from other providers and the patient in compliance with Health Home standards.
• Collaborate with patient and care team to implement plan of care towards achieving goals.
• Conducts home/field visits and maintains patient contact in accordance with program standards.
• Coordinates patient services with internal and external service providers through regular care conferencing.
• Documents all patient related encounters and interventions in patient’s chart per established workflow.
• Update plan of care with outcomes of interventions per established workflow.
• Assist in coordinating care with pharmacies, managed care organizations (MCOs), hospital discharge planning and other members of patient’s care team.
• Conducts and documents initial comprehensive assessment in accordance with Health Home and State guidelines.
• Completes annual reassessment in accordance with Health Home and State guidelines.

Requirements

• Bachelor's/Master's Degree with (2) years experience in care coordination is preferred.
• Associates Degree with (4) years experience in care coordination.

Skills

• Bilingual Spanish a plus

Location

• Brooklyn
• Bronx
• Queens
• Manhattan

Work Type

• Full-time

Experience Level

• 2 years experience in care coordination
• 4 years experience in care coordination

Education Level

• Bachelor's Degree
• Master's Degree
• Associate's Degree

Benefits

• Health insurance
• Dental insurance
• Vision insurance
• Retirement plans
• Employee assistance programming

About the Company

• Community Healthcare Network (CHN) is a not-for-profit organization providing more than 65,000 New Yorkers with primary and behavioral healthcare, dental, nutrition, wellness, and needed support services.
• Our network is made up of 14 federally qualified health centers throughout Brooklyn, the Bronx, Queens, and Manhattan, along with a fleet of mobile vans that bring health services to underserved people in need throughout New York City.
• We provide judgment-free, high-quality healthcare, without regard to race, religion, orientation, gender identity, immigration status or ability to pay.
• We turn no one away.