Care Manager, Health Home

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 conditions and for facilitating clients’ access to the full range of medical and psychosocial services in an efficient and effective manner. The Care Manager is mainly responsible for coordinating medical care by receiving inpatient and ER admissions of targeted clients. In addition, the Care Manager is responsible for visiting clients during inpatient stays and participating actively in discharge planning and care transition activities.

Essential Job Functions

The following duties are mandatory requirements of the job:

  • Complete intakes, assessments, reassessments, and develop care plans.
  • Conduct home visits and community follow-up to monitor services and the client’s status.
  • Participate in case conferences with other providers.
  • Attend weekly supervisory meetings.
  • Maintain contact with the client’s extended family and informal support networks.
  • Escort clients to/from service provider appointments when necessary.
  • Monitor client’s progress in utilizing services.
  • Work closely with the interdisciplinary care team including PCP, psychiatrist, therapist, residential services, and substance abuse treatment program.
  • Work closely with the Care Navigator to ensure the flow of information across and between the care team is optimized.
  • Conduct care coordination with providers/family for written individualized care plans.
  • Review client’s intake assessment and uses identified needs to coordinate the completion of the care plan.
  • In conjunction with the client, the Care Manager is responsible for identifying potential barriers to care and identify possible resolutions to those barriers;
  • Conduct outreach to clients who have not met treatment.
  • Evaluate medication compliance and assess potential barriers to adherence; ensure medication reconciliation is current.
  • Contact clients on the day of discharge from inpatient services and ER or within 24 hours.
  • Outreach to clients to facilitate keeping scheduled appointments; arranges for metabolic and periodic preventive screening, per evidence based guideline standards.
  • Ensure that clients and care givers are aware of test results by facilitating a discussion between the client and physician as necessary.
  • Coordinate 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.
  • Provide or arranges for provision of self-management/ wellness education, peer and other support groups in the language that the client/family prefers.
  • Organize and participates in case conferences on a periodic basis, as necessary.
  • Review benefits, entitlements, housing with the client/family and assist in the application process. Follows up as necessary to ensure services are approved.
  • Assist in crisis intervention

Other Responsibilities

The following duties are to be performed as assigned by the supervisor:

  • Participate in CQI activities.
  • Identify quality of care issues and refers to appropriate departments/services.
  • Participate in conferences, workshops, and other professional development activities to maintain licensure and/or remain professionally current with advances in field of expertise.
  • Participate in multidisciplinary task forces, committees and projects.
  • Perform other related duties as required.

Minimum qualifications

Education: Bachelor degree required.

Experience: Preferably 1-3 years of experience in healthcare, social work, case management, or discharge planning.

Special skills and knowledge

  • Excellent computer skills necessary.
  • Able to use word processing, spreadsheet and/or database programs as required by the position.
  • Excellent oral and written communication skills.
  • Excellent interpersonal skills.
  • Good problem-solving, decision-making and judgment skills.
  • Must read, write and speak English to the extent required by position; knowledge of second language preferred.

How to apply

Harlem United is an Equal Opportunity Employer.

Qualified candidates should forward cover letter and resume to Anusky Mojica,

New York, New York
Harlem United Community AIDS Center
Anusky Mojica