Health Home Care Manager

Job description

Health Home Care Manager Job Description

Position Summary:

The Health Home Care Manager provides professional consultative, investigative, advisory, and educational support for members and families, site staff, and collaborative community agencies. Consistent with New York State regulations and policies for the provision of Health Home services, the Health Home Care Manager conducts patient-level data analyses to track patient adherence to treatment protocols and performs nonclinical interventions to assist patients in developing service plans to overcome barriers to access and care. The Care Manager communicates and collaborates regularly with patients, physicians, community agencies, and office staff to adapt and refine and address support mobilization as needed.

Clinical Responsibilities & Duties:

With significant independence and latitude for action, the Care Manager serves as a liaison and patient advocate between patients and their practice team, specialists, and community agencies to assist and educate them in overcoming barriers to care. Health Home Care Managers are to:

• Complete initial and annual comprehensive assessment of medical, behavioral health, and social service needs for the assigned Health Home enrollees.

• Provide disease-specific education and information regarding community resources.

• Collaborate with a variety of community providers and resources to obtain needed services and support, utilizing community and family resources to create a sustainable support system.

• Request and coordinate team and patient meetings as needed or requested by patient/family and/or team and/or escalate care management when medical assessment is needed.

• Ensure diagnostic, posthospitalization, and specialty referrals have been executed and results received and acted upon as needed.

• Document plan of care, patient utilization, activities, and other required information with the State and EMR.

• Monitor assigned enrollees' utilization of services, ensuring care is accessible, attended and effective

• Provide regular data to the team on patient compliance and strategies to improve patient compliance

• Participate in HH care management discipline training

• Participate in on-call activities as directed/scheduled by the Program Coordinator

• Participate in regularly scheduled team meetings as prescribed by the practice's policy

• Participate in cultural competency events and training appropriate to job duties

• Assisting patient and family in developing service plan goals

• Frequent nonmedical management coaching, education, follow-up visits and phone calls to patients to monitor progress and identify new barriers or concerns

• Assisting with financial or other social issues that may provide barriers to patient compliance

• Providing education/guidance to patients and family on tools to manage chronic illnesses, developing individual and web-based tools and resources to improve compliance

• Identifying and connecting patients with community resources to assist with improving compliance with treatment protocols and social issues (e.g. legal aid)

• Accurately and timely document all interventions into prescribed electronic medical record systems to ensure timely reimbursement in compliance with New York State Health Home regulations and Patient-centered medical home regulations.

• Participate in patient/outpatient care training regarding the care management strategies for difficult-to-manage patients, and educate office staff on patient or office system issues, including communicating patient care inconsistencies between the primary care physician and referring specialists.

Qualifications

• The Health Home Care Manager must have a BA and a minimum of 2 years of relevant experience in Human Care Services

• Excellent communication and team skills including the ability to form strong collaborative interdisciplinary partnerships across care settings

• Sound computer knowledge and skills including an aptitude for using health information technology to guide activities

• Ability to work independently and meet deadlines. Creativity and strong organizational skills

• Valid NYS driver's license including access to reliable transportation that enables fulfillment of the position's travel requirements