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About the Role
Cornerstone Family Healthcare is seeking a Health Homes Care Manager to provide core components of care coordination to individuals with chronic illnesses, including mental health conditions and HIV. The Care Manager will manage a dedicated caseload and be assigned a primary office location.
Responsibilities
- Engage and assess Health Home clients to coordinate care using a shared care plan.
- Complete documentation in compliance with DOH, Health Home, and Agency standards.
- Coordinate with service providers to ensure all client needs are addressed.
- Provide proactive care management and develop client-centered care plans.
- Utilize electronic health records for effective care coordination.
- Engage new Health Home clients and maintain engagement in care coordination.
- Conduct intake and comprehensive health assessments/reassessments, identifying mental health, chemical dependency, and social service needs.
- Develop comprehensive, measurable, goal-oriented care plans in collaboration with external providers.
- Advocate and assist clients in obtaining and maintaining entitlements and housing.
- Assist and support clients in treatment adherence recommendations.
- Refer and follow-up on referrals for clients to ensure medical stabilization.
- Coordinate hospital discharges and follow-up on recommendations from ER, hospital, or acute care facilities.
- Assist clients and their families in resolving barriers to obtaining medical services.
- Escort clients to appointments when necessary.
- Conduct home and field visits.
- Maintain ongoing contact with interdisciplinary medical providers, acting as team leader.
- Provide crisis intervention when required.
- Meet and maintain program productivity standards.
- Maintain Electronic Health Record and all required electronic data.
- Track and maintain a system of patient medical appointments, labs, and other critical time-sensitive activities.
- Complete all program standards documentation as required.
- Participate in supervision and program review each week.
- Attend and participate in monthly department, All Staff, and other required meetings.
- Be familiar with Cornerstone policies and procedures and the Employee Handbook.
- Maintain confidentiality of all aspects of Cornerstone.
- Perform other related duties as assigned.
Requirements
- Master’s degree in social work or related degree with some experience in the field.
- Bachelor’s degree in social work or related degree with some experience/knowledge in case management, chemical dependency, mental health, and/or human services.
- LPN with 1 year of experience providing case management or medical coordination among multiple providers.
- Computer experience must include Microsoft Word and Excel.
- Access to a car and valid driver’s license are required.
Skills
- Care coordination
- Documentation
- Electronic health records
- Microsoft Word
- Microsoft Excel
- Crisis intervention
Location
- Monticello, NY
Work Type
- Full-time
Education Level
- Master's degree
- Bachelor's degree
- LPN
Salary/Compensations
- $25.00 per hour
Benefits
- Competitive salaries
- Health Benefits
- Retirement plan
- Paid Time Off
- Sick Time
- Flexible Spending
- Dependent Care
- Paid Holidays
About the Company
- Cornerstone Family Healthcare is a non-profit Federally Qualified Health Center.
- Mission: To provide high quality, comprehensive, primary and preventative health care services in an environment of caring, dignity and respect to all people regardless of their ability to pay.
- For over fifty years, Cornerstone has been responsive to meeting the needs of the communities in which we serve with a continued emphasis on the underserved and those without access to health care regardless of race, economic status, age, sex, sexual orientation or disability.