Sun River Health a Federally Qualified Health Center system with over 40 locations, serving more than 245,000 patients throughout the Hudson Valley, New York City, and Long Island. Our belief stands firm: being healthy should not be a privilege for a few, but a right for all. As we move forward, we will continue to provide high-quality health care for everyone in our communities Our exceptional primary care practitioners, specialists, and support staff have made us a destination for affordable, high-quality care.

We are seeking a reliable and talented Care Manager to join our Brooklyn Church Avenue Health Center!

Must be flexible to some work in the field. This position is Full Time onsite Monday-Friday

SUMMARY OF POSITION:

The Health Home Care Manager provides care coordination and support to clients with chronic medical and behavioral health conditions that are also impacted by social determinants of health. Assists clients navigate social service, community, and healthcare systems.

ESSENTIAL FUNCTIONS:

• Completes comprehensive assessments within the required timeframes. Maintains detailed, accurate and timely case notes. Conducts intakes as needed
• Facilitates enrollment in Benefit and Entitlement programs. Develops linkages and refers patients for additional service supports
• Provides timely and appropriate follow up on newly referred clients
• Provides Health Home Care Management services at community-based locations and within the Sun River health centers
• Facilitates periodic case record reviews and case conferences with all providers serving the client
• Provides linkage, coordination with, referral to and follow-up with appropriate ongoing service providers, including mental health and medical specialists
• Case conferences with interdisciplinary team including but not limited to PCP, substance abuse treatment team, residential, hospital discharge planners, etc., to coordinate care delivery between all linked providers and client
• Conducts field work to meet their clients in the community
• Maintains data and case records as required and prepares necessary reports
• Develops, coordinates and integrates a coordinated care plan in cooperation with the client, the client’s family, and/or the other providers serving the patient. Updates plan at specified intervals, and as needed based on changes in client’s condition / circumstances
• Performs and maintains effective care management for a caseload of clients, as assigned, from assessment to discharge
• Tracks/ monitors client progress and produces/maintains detailed, accurate and timely case notes
• Maintains updated case records through health home EMR, and coordinates effective electronic communication throughout all provider databases, as needed. Maintains case records in accordance with health home policies/procedures, agency standards and regulatory requirements
• Participates and consults with team supervisor in case conferences, staff meetings, and discharge planning meetings to determine if client requires an alternate level of care or is appropriate for discharge

EDUCATION/EXPERIENCE:

Bachelor’s degree preferred in Health or Human Services related field with 2 years of related work experience

High School Diploma/GED Required