Care Manager of Health Home Care Management

Sun River Health provides the highest quality of comprehensive primary, preventative and behavioral health services to all who seek it, regardless of insurance status and ability to pay, especially for the underserved and vulnerable. Sun River Heath is a Federally Qualified, Non-Profit Health Center serving communities in Suffolk, Rockland, Orange, Dutchess, Ulster, Sullivan, Columbia and Westchester County. Sun River Health is currently seeking a full-time Care Manager to support our site in Riverhead.

A Care Manager provides care management for specified patients in need of care management at Sun River Health. These patients may be referred by providers/clinical team; or enrolled in NYS Health Home Program or be included in care management as part of a grant, insurance program or disease specific program. Links patients to preventive and primary health care services including care for: acute, chronic and communicable diseases; dental services; prenatal care and family planning; WIC and other nutrition services; pediatric care and immunizations; and behavioral health or substance abuse programs as needed. This includes assistance with community resources, social services, and referrals. This position will be responsible for proper and timely documentation with ECW and any designated care management software, as well as communication with internal and external referral sources. Performs other duties as assigned on an as needed basis.

Essential Duties and Responsibilities of a Care Manager:

• Responsible for completing outreach and subsequent intake activities using required forms and documents as required. This may include program specific additional consents and assessment tools. Document as directed in ECW and designated program software.
• Consult with multidisciplinary team on client’s care plan/needs/goals. This may include participation in case conferencing. May also include family members and social supports.
• Responsible for referring patients to needed services as directed by provider to support care plan/treatment goals; including medical/behavioral health. Responsible for release of all necessary clinical information to specialist referral; tracks referral appointments and obtain consultant reports with appropriate consent for release of information and documents process in eCW per HRHCare procedure and designated software for care management.
• Consult with health care team to link patient to community/ social services programs and entitlements: including application assistance; transportation assistance; translation services; housing services; self-help recovery and self-management programs as needed. Document.
• Conduct client outreach and engagement activities at least monthly to evaluate for on-going emerging needs and to promote continuity of care and improved health outcomes. Document.
• Follow up with Hospitals/ ER upon notification of admission or discharge and coordinate with health care team to facilitate communication of the event and transition of care services, to include, but not limited to medication reconciliation with the health care team as per policy.
• Assist patient in developing plans and community supports to overcome obstacles that would prevent them from receiving needed services/referrals.
• Provide basic instruction/health education to clarify provider instructions, procedures and referral needs.

Minimum Education Requirement:

• High School diploma/GED
• Creditable Alcohol and Substance Abuse Counselor in Training optional for Substance Abuse Program only. Previous experience working with underserved communities.

Preferred Education Requirement:

• Associate's degree with CASAC-T

Minimum Work Related Experience: 2 - 4 years

Preferred Work Related Experience: 5 - 8 years

Hourly Range: $23.00 - $28.75 p/hr