Health Home Care Manager

The Care Manager has overall day-to-day responsibility for coordinating the activities of the care team for clients with complex medical and/or psychiatric co-morbid conditions and for facilitating clients’ access to the full range of medical and psychosocial services in an efficient and effective manner.

QUALIFICATION:

· Bachelors in Social services field

· 1 years of experience in healthcare, social work, case management experience preferred.

· Strong written and verbal skills

· Excellent computer skills are necessary, demonstrated ability to use word-processing, or data base programs.

· Knowledge of community resources, and entitlements.

· Good organizational and interpersonal skills.

· Knowledge of a second language preferred (Bilingual Russian/Spanish/ Punjabi/Hindi)

RESPONSIBILITIES

· Participates in conferences, workshops, and other professional development activities to remain professionally current with advances in field of expertise.

· Continually reviews the service delivery process.

· Participates in multi-disciplinary case conferences and projects, demonstrating team spirit and ability to work with other community-based organizations to meet clients’ needs.

· Works closely with the interdisciplinary care team including PCP, psychiatrist, therapist, residential services, substance abuse treatment program, etc.

· Works closely with the Supervisor/Director to ensure the flow of information across and between the care team is optimized.

· Provides input to providers/client/family for written individualized care plans.

· Reviews client intake assessment and uses results to coordinate the completion of the care plan, self-management goals and strategies; documents them in EMR.

· In conjunction with the client, identifies potential barriers to care and resolutions to those barriers; outreaches to clients who have not met treatment goals to resolve barriers/adjust goals when possible.

· Evaluate medication compliance and assess potential barriers to adherence; ensure medication reconciliation is current.

· Receives alerts in client and ER admissions of targeted clients, visits clients during client stays and participates actively in discharge planning and care transition activities; and contacts clients on the day of discharge from client services and ER or within 24 hours.

· Outreaches to clients to facilitate keeping scheduled appointments; arranges for metabolic and periodic preventive screening, per evidence-based guideline standards.

· Ensures that clients and care givers are aware of test results by facilitating a discussion between the client and physician as necessary.

· Coordinates services between client and extended care team providers to ensure that integrated care plan is fully implemented.

· Regularly reviews client information from care team members to identify clients requiring outreach and engagement and identifies quality of care issues and refers appropriately.

· Provides or arranges for provision of self-management/ wellness education, peer and other support groups in the language that the client/family prefers.

· Reviews benefits, entitlements, housing with the client/family and assist in the application process. Follows up as necessary to ensure services are approved.

· Remain sensitive and responsive to the cultural and religious differences present in the clinic’s client population and staff.

· Undertake any additional tasks and initiatives as assigned by the Program Supervisor or Director.

Job Type: Full-time

Pay: $40,000.00 - $50,000.00 per year

Benefits:

• 401(k)

People with a criminal record are encouraged to apply

Work Location: In person