Care Manager I - HH

POSITION SUMMARY:

The role of Health Home Care Manager (HHCM), primary function is guiding chronically ill patients through the health care system by assisting with access issues, developing relationships with service providers, and tracking interventions and outcomes. The HHCM acts as the team leader, provides direct services to patients including the completion of needs assessments, development of patient focused care plans, periodic reassessments and overall comprehensive service coordination.  The HHCM also functions as an advocate for clients within the agency and with external service providers.  As a team leader, the HHCM is ultimately responsible for the overall provision and coordination of services to assigned patients.

The HHCM works closely with the patient’s Care Team (Provider, medical assistant, nurse, behavioral health provider, social worker, etc.) to coordinate all aspect of care inclusive of appointments, referrals, adherence, specialty care, etc. The HHCM will act as a primary conduit for the transmission of information between providers and patients. The HHCM will coordinate services for all assigned patients who have serious, chronic health problems, persistent mental health conditions, and substance use disorder (SUD). The HHCM will provide advocacy, information, and referral services to patients and families to address their medical and psychosocial needs.

DUTIES AND RESPONSIBILITIES:

Essential Functions:

1. Provides direct service to a caseload of approximately 60 patients. 
2. Provide patient and family support by way of linkage to community resources.
3. Conducts and documents initial assessments of patients’ needs including medical, mental health, substance use and social determinants of health within 60 days of enrollment. 
4. Provides crisis intervention and health education services as needed.
5. Develops individualized patient centered plan of care with documented input and approval from other providers and the patient in compliance with Health Home standards. 
6. Collaborate with patient and care team to implement plan of care towards achieving goals.
7. Conducts home/field visits and maintains patient contact in accordance with program standards.
8. Coordinates patient services with internal and external service providers through regular care conferencing.
9. Documents all patient related encounters and interventions in patient’s chart per established workflow.
10. Update plan of care with outcomes of interventions per established workflow.
11. Assist in coordinating care with pharmacies, managed care organizations (MCOs), hospital discharge planning and other members of patient’s care team. 
12. Conducts and documents initial comprehensive assessment in accordance with Health Home and State guidelines.
13. Completes annual reassessment in accordance with Health Home and State guidelines.
14. Prepares for and facilitates team meetings to delegate plan of care tasks to care team members.
15. Maintains timely and effective communication with care team regarding all relevant matters pertaining to patient care.
16. Reviews providers’ schedules and individual patients’ charts, to assist the care team in coordination of care for current and future visits.
17. Uses registry and other care plan information to inform care team members of care plan implementation required for each patient.
18. Monitor of patient’s adherence to their medical appointments.
19. Responds to patient’s complaints and concerns according to CHN and Health Home policy guidelines.
20. Participate in Quality Assurance (QA) and Quality Initiative (QI) projects.
21. Develops knowledge and awareness of available community resources in order to assist patients in achieving plan of care goals and addressing social determinants of health.
22. Provides excellent customer service according to CHN guidelines.
23. Compliance with Employee Health Services.
24. Ensures that services provided to patients are appropriate with respect to privacy and confidentiality of protected health information (PHI) in a manner consistent with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
25. Provides coverage and support to other care team members as needed or assigned.
26. Perform other duties as assigned.

HIPAA

The HHCM will have access to PHI during the course of his/her work activities. The HHCM will use this information to prepare the care coordination that will occur during the patient’s visits with the provider and to keep the flow of work going smoothly in the clinic. ALL HIPPA, corporate compliance, and Health Home guidelines must be maintained and kept at all times

Other Functions:

1. Special projects as assigned by the Program Director/VP of HH/VP of Social Services.
2. Participates in designated program meetings.
3. Participates in Center staff meetings.
4. Participates in relevant internal and external training.
5. Performs other related duties, as assigned.

CERTIFICATE/LICENSE REQUIRED:

• LPN/MSW/MPH/BA/BS Degree is required. Two (2) years experience in care coordination is preferred. 

KNOWLEDGE, SKILLS AND ABILITIES REQUIRED:

• Proficiency in verbal communication in English.
• Demonstrated ability to work effectively in a team environment.
• Demonstrated problem solving skills in a complex environment.
• Demonstrated effective interpersonal relationship and customer service skills.
• Good organizational and time management skills.
• Good working knowledge of local social service resources or skills to acquire and use this knowledge and information expeditiously.
• Ability to work effectively with people from diverse cultures and diverse socioeconomic situations.
• Basic level of skill with Microsoft Word, Excel and ability to use other computer programs and applications (EMRs, etc) in ways that facilitate disease/care coordination management.

PHYSICAL DEMANDS/WORKING CONDITIONS:

1. Ability to stand, walk or sit for an extended period of time.
2. Ability to hear within normal range.
3. Ability to see within normal range.
4. Excellent verbal and written communications skills.
5. Ability to deal with agitated patients and staff.
6. Extended periods of time at a computer.
7. Finger and hand dexterity to manipulate objects.
8. Extensive travel on public transportation (only bus & train) to and from sites.
9. Noise level is moderate.
10. Possible exposure to inclement weather when conducting field work.
11. Travel to unsafe neighborhoods.
12. Possible exposure to patients with infectious diseases.
13. Ability to communicate easily and display a cordial manner towards individuals from a variety of socio-economic, cultural and religious background.

The physical requirements described herein are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made, whenever possible, to enable individuals with disabilities to perform the essential functions.