Health Home Care Manager - Adult Pcod

Open Door Family Medical Center provides health care and wellness programs to individuals and families in need throughout Westchester, Putnam and Ulster Counties. A pioneer Federally Qualified Health Center, Open Door provides more than 300,000 patient visits annually and serves nearly 60,000 individual patients who might not otherwise have access. Open Door offers integrated services and a holistic approach to building healthier communities. Primary medical care, dental care, integrated behavioral health care, clinical nutrition, wellness programs, and chronic disease management are the foundation of its clinical programs.

Founded as a free clinic in 1972, Open Door’s mission of building healthier communities through accessible, equitable, culturally competent health care has led to site and service expansions. Today, Open Door operates centers in Brewster, Mamaroneck, Mount Kisco, Ossining, Port Chester, and Sleepy Hollow, in addition to eight School-Based Health Centers in the Port Chester and Ossining School Districts, a mobile dental van in Mount Kisco, and a new dental practice in Saugerties, NY.  For more information, please visit our website at www.opendoormedical.org.

Open Door is seeking a Health Home Care Manager to be based in Purchase, NY reporting to the Manager, Care Management Programs. This position will work with adults with Medicaid who have chronic medical and behavioral health conditions to improve health outcomes, develop self-management skills and reduce unnecessary emergency room/hospital visits.  The Care Manager will conduct assessments, work with enrollees to establish care plan goals, provide health education and assist with coordination of medical and social services.  This position will provide support to patients receiving primary care at Open Door and travel to Open Door locations and community locations to provide services is required. For more about the New York State Health Home program, please see:  https://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/  

Responsibilities:

• Outreach individuals referred to the program and engage them into the program.
• Conduct assessments to identify individualized needs related to psychosocial well-being, physical health and the social determinants of health.
• Based on the findings from the assessment, collaborate with enrollees to set goals and develop a care plan; monitor goal achievement and revise the care plan.
• Utilize Motivational Interviewing and other techniques to assist in goal setting and achievement.
• Coordinate and arrange for the provision of medical, behavioral health, social and other relevant services, including appointment scheduling, appointment reminders and transportation booking.
• Accompany enrollees to appointments both on- and off-site.

• Collaborate with family members/caregivers as well as internal and external service providers.
• Model and coach enrollees on medical/behavioral service navigation with the aim of empowering enrollees to become independent, effective health care consumers.

• Conduct home visits to provide services to enrollees and assess the enrollees’ living environment.
• Support enrollees in adherence to treatment recommendations from medical and behavioral health providers.
• Provide health education to assist with enrollees’ understanding of physical and behavioral health conditions and treatment and link enrollees with evidence- and research-based resources.
• Discuss advance directives and health care proxies with enrollees and their families or caregivers.
• Retain enrollees in care over time.
• Maintain a caseload of 50 individuals.
• Complete all documentation as required including data entry into New York State data portal and Open Door’s electronic medical record.

• Master’s Degree preferred; candidates with a Bachelor’s Degree and solid work experience will be considered as well.  Degree in Social Work or social sciences preferred; other degrees with relevant experience will be considered.
• Fluent in English and Spanish is required.
• Minimum two years’ experience in healthcare and/or social services settings; case/care management experience a plus.
• Must have valid NYS driving license and daily access to car.
• Proficient computer use including MS Office applications, especially Excel; experience with electronic health records or case management software a plus.
• Must have valid New York State driver’s license and daily access to a car.
• Strong written and verbal communications skills.
• Passionate about providing high quality care to low-income, under-served individuals and those lacking access to health care.
• Patient-centric, engaging and empathetic with strong active listening skills.
• Comfortable providing direct patient care to adults of all ages with an array of chronic medical and behavioral health needs.
• Competence working with culturally diverse client and staff populations.
• Able to navigate healthcare and community settings as well as enrollees’ natural settings (i.e. place of residence).
• Collaborative and effective when working with a team of service providers.
• Responsive and comfortable in a fast-paced, high-accountability environment.
• Highly organized, self-directed, able to multi-task and be flexible.

• Effective problem solver, exhibiting excellent judgment and the ability to prioritize.

Open Door offers its employees a stimulating, diverse and team-based work environment with comprehensive benefits including medical, dental, vision and life insurance, flexible spending accounts, 403(b) and a matching 401(k), generous paid time off, onsite Wellness facilities, mileage reimbursement and educational assistance.  At Open Door, we enjoy working in a team-based, patient-centered environment and value the benefits of a diversified workplace that values our patients and the communities we serve.

If you want to make a difference in the lives of thousands of patients in the health of our communities of Westchester and Putnam counties, and if the position speaks to your capabilities, experience and commitment to improve the health of our communities, please submit your resume and cover letter with salary requirements. Qualified candidates will be contacted by phone and/or email.

Open Door is an Equal Opportunity Employer.