About Job

Summary of Position:

The Community Care Manager (CCM) coordinates care for individuals with chronic conditions and mental illness by developing a person-centered plan of care and connecting them to medical, behavioral, and social services. They work closely with healthcare providers, community resources, and patients to ensure comprehensive support, improve health outcomes, and reduce unnecessary hospitalizations. The CCM provides care coordination, patient advocacy, and ongoing support to address barriers to care. Through education, advocacy and resource navigation, the CCM empowers patients to manage their health more effectively.

Primary Job Responsibilities:

Verifies and documents eligibility for services.
Conducts a thorough needs assessment and works with the patient to develop a comprehensive care plan based on the patient’s needs, strengths, and priorities.
Provides extensive and intensive case management and follow-up services.
Provides interventions and service coordination to eligible populations
Utilizes knowledge of federal, state and local resources to make appropriate referrals.
Meets the patient at their preferred location, including conducting home visits as necessary.
Advocates and interacts with other service providers on behalf of eligible populations.
Maintains current and accurate documentation of services.
Works collaboratively with other Care Managers and SHMG leaders to coordinate services, integrate operations to the highest level possible and ensure seamless delivery of care and services.
Establishes positive working relationships with all levels of management, physicians and staff.
Attends meetings and serves on committees, as requested.
Accepts responsibility for all aspects of job functions without blame, complaining, or procrastination.
Ensures compliance with NYSDOH requirements.
Contributes to continuous quality improvement initiatives and assures compliance with all regulatory requirements.
Maintain documentation and statistics on activities to comply with reporting requirements.
Provides reports and statistical information, as requested.
Adheres to HIPAA confidentiality regulations 100% of the time.
Performs other duties as assigned.

Minimum Qualifications:

Education, Training & Experience

Master’s degree in a qualifying field and 1 year of experience or Bachelor’s degree in a qualifying field and 2 years of experience, or CASAC and 2 years of experience.

Preferred Qualifications:

Previous Health Home Care Management experience highly preferred
Previous experience serving the behavioral health population preferred
Must be able to use Microsoft Outlook, Excel and other proprietary software.
Must be able to pass background checks.
Experience using Netsmart Care Manager Preferred
Knowledge of community resources
Excellent customer service skills
Able to work a flexible schedule.
Proven experience engaging hard to serve populations

Certifications / Licensure

Must possess a valid driver’s license.

Required Skills, Abilities and Attributes:

The candidate must be able to work in a hybrid environment, with a combination of remote, in-office, and community-based work as required.
Demonstrated ability to work both independently and as part of a team.
Demonstrated ability to establish and maintain collaborative inter-agency relationships.
Exceptional communication skills, both verbal and written.
Ability to develop and maintain strong working relationships.
Ability to influence others to work towards common goals.
Strong facilitation skills and team-building skills.
Ability to work collaboratively as part of a matrix leadership team at all levels of interaction within a highly complex organizational structure.
Critical thinking skills – ability to manage in a fast paced, demanding environment with a sound thought process and composure.
Stooping, bending, reaching, walking, manual dexterity and visual acuity.
Sitting or extended periods of time at a computer terminal
Must be willing to travel within SHMG service area.