Position: Care Manager.

Description: The Care Manager (CM) works with Medicaid Health Home clients with complex healthcare needs, and responsibility for overall management of a caseload of approximately 25-30 clients.

Responsibilities

• Responsible for the overall caseload management and case management team service delivery.

• Conduct comprehensive assessments or reassessments inclusive of medical, behavioral, rehabilitative and long-term care and social service needs.

• Develop and implement individualized patient-centered care plans to identify the member’s needs and goals and include family members and other social supports as appropriate.

• Case conference with a primary care physician and/or specialists and other care team members identify and involved in the member’s care plan.

• Refer and link the client to needed services to support care plan goals, including medical/behavioral health care, patient education and self-help/recovery and self-management.

• Following up with the hospital or ER upon notification of a client's admission and/or discharge.

• Facilitating discharge planning from an ER, hospital, residential or rehabilitative setting to a safe transition/discharge where care needs are in place.

• Coordinate the provision of services including as per their acuity level.

• Support adherence to treatment recommendations.

• Monitor and evaluate a client’s needs, including prevention, wellness, medical, mental health, care transitions, and social and community services as appropriate.

• Complete all required internal and external trainings.

• Adhere to agency personnel policies, expectations and professional requirements.

Qualifications, Experience & Requirements

Education: Bachelor’s degree and/or CASAC certification.

Experience: 2 years case management, care coordination or case management experience, working in community-based programs. Experience working with Medicaid, chronically ill and/or functionally challenging populations.

Technical skills: computer literacy, EMR/database familiarity, proficiency/familiarity with mobile technology.

Cultural competence: awareness of and ability to work non-judgmentally with diverse and culturally complex populations.

Interpersonal skills: critical thinking skills, writing and oral communication skills; energetic and positive approach to working with in an evolving and challenging environment.

Travel: ability and willingness to travel throughout NYC.

Language: bi-lingual (English/Spanish) preferred.