Health Homes Care Manager

Refugee & Immigrant Self-Empowerment, Inc.
412 Niagara Street

Job Title

CARE MANAGER

Status: 40 hours/week; Compensation Based on Experience

Location: Buffalo, Onondaga County

Case Load: A minimum of 38 client caseload

Reports To: Director of Care Management

Organization Description: Refugee & Immigrant Self-Empowerment, Inc. (RISE), formerly known as the Somali Bantu Community Association (SBCA), was founded by Somali Bantu refugees in 2004 to ease the transition of other members of the resettled Somali Bantu community living in Onondaga County. With the influx of the refugees that come to Syracuse, RISE remains committed to assisting the diverse refugee and immigrant communities in Onondaga County. Our programs are targeted at promoting self-sufficiency through employment, education, and economic empowerment.

Program Summary: RISE’s Care Management Department serves as a downstream Care Management Agency for the New York State’s lead Health Homes. RISE Care Management assists New Americans with limited English proficiency in navigating the paperwork, phone calls, medication, and appointment scheduling necessary for coping with complex chronic medical conditions.

Care management also includes but is not limited to housing assistance and referrals, family and personal crises intervention, interpretation and translation, community resource referrals, and mediation services.

Position Summary: RISE Care Managers offer comprehensive care management, care coordination and health promotion, comprehensive transitional care, patient and family support, and referrals to community and social supports. He or she is responsible for maintaining the RISE Culture of Care by respectfully working closely with clients and their families, documenting, monitoring, and evaluating their progress with a high level of cultural competency and self-awareness.

Responsibilities: Duties of the Care Manager include, but are not limited to:

1) Provides connection to a range of services that link clients with health care and behavioral health treatment and psychosocial services as dictated by a client centered plan of care.

2) Provides a network wide focus to the coordination and management of client care.

3) Works closely with family members when appropriate and all service providers to ensure that client’s needs in medical, behavioral, and psychosocial domains are met and maintained.

4) Responsible for client outreach, enrollment, health assessment, care plan creation, and appropriate follow-up.

5) Documenting, monitoring, and evaluating client progress in electronic medical record (EMR) and electronic health record (EHR) and intervening as necessary.

6) Pre-screen clients for eligibility based on NYS health home qualification standards

7) Proactively inform clients of RISE’s available programs and services, as well as services provided elsewhere

8) Equitably and consistently adhere to legal, organizational, and program-specific laws and policies.

9) Ensure that all formal client interaction is retained thoroughly, accurately, expeditiously in EPIC with a minimum of two monthly documentation encounters per client.

10) Collaborate with clients to develop, implement, and regularly monitor care plan goals/outcomes and strategies

11) Establish and maintain respectful, professional, culturally sensitive, appropriate boundaries with clients

12) Provide or facilitate education and assistance focusing on client’s needs, rights, and responsibilities

13) Assist clients and their families in applying to external resources.

14) Conduct on-site visits to client homes as necessary.

15) Regularly communicate reports, data, and other salient information to the Care Management Supervisor.

16) Attend RISE fundraisers and other company wide events as necessary.

17) Be present in the RISE office during assigned office hours and present in the office as needed.

18) Adhere to Care Management on-call policy using the HIE myAlerts system.

19) Adhere to strict confidentiality practices, including but not limited to HIPAA.

Requirements: Prerequisites of the Care Manager include:

1) Associate or 4-year degree required

2) Fluent proficiency in English

3) One or more languages used by the communities RISE serves preferred

4) Interpersonal ability to cultivate and maintain enduring and trusting client-centric relationships

5) Advanced proficiency in written and verbal communication; strong communicative and collaborative ability

6) Advanced proficiency in technology and computer skills

7) Strong ability to counsel, make data-driven decisions, organize, mediate, and resolve conflict

8) Ability to document, organize, navigate, and communicate data using administrative systems

9) Strong ethical and professional conduct; strong passion for human services preferred

10) Strong prioritization and time management skills; proactive bias towards action

11) Intermediate proficiency in Microsoft Office and Google Apps preferred

RISE is an equal opportunity employer which values diversity, equity, and inclusion. We are

committed to a continued focus on equitable hiring, training, promotional practices, and

policies. We are a drug free workplace and comply with ADA regulations, as applicable.

If you are interested, please apply with your resume and cover letter.

Job Type: Full-time

Pay: $19.85 - $23.80 per hour

Benefits:

• 401(k) matching
• Dental insurance
• Flexible schedule
• Paid time off
• Parental leave

Work Location: In person