Health Homes Care Manager

Company Name:
ER Family of Companies
Are you passionate about helping others? Trillium Health along with ER Associates seeking to fill a Care Management position in Bath, NY. Ideal candidates will have past experience working with individuals with chronic illnesses. Strong background in casework as well as an RN is required. This is an excellent chance to join a growing organization!


1. Care Management
Provide client-centered, quality driven, culturally appropriate comprehensive care management to patients diagnosed with a chronic illness and their families in compliance with agency policies and funder requirements.
Assist in the reduction of avoidable health care cost specifically; (1) preventable hospital admissions/readmissions and (2)avoidable emergency room visits by providing timely post discharge follow-up and improving patient outcomes
Responsible and accountable for coordinating all aspects of the client's care
Create, document, execute and update an individualized patient centered plan of care for each individual that includes community-based and other social supports services in addition to healthcare services that respond to the client's needs and preferences and contribute to achieving the client's goals
Ensure that the plan of care is individualized and clearly identifies goals and timeframes for improving the client's health and health care status and include interventions that will produce positive outcomes
Complete periodic reassessments of the plan of care to (1) reassess the needs of the client, (2)identify the client's progress in meeting their goals and; (3)make changes to the plan of care based on changes in the client's need
Provide ongoing monitoring of the care plan and of each client's needs, e.g., prevention, wellness, medical, specialist and behavioral health treatment, care transitions and social and community services
Coordinate and provide access to preventive and health promotion services through the Health Home Network and other community resources
Discuss with the clinician, on an as needed basis, changes in the client's condition that may necessitate treatment changes (i.e., written orders and/or prescriptions) and provide feedback to practices as feasible and appropriate
Build relationships with the clients and all members of the treatment team to support continuity of care and promote health
Coordinate and participate in regular case review meetings that include all members of the interdisciplinary team
Demonstrate the ability to use the health information technology system to coordinate and link services
Identify available community-based resources and actively manage appropriate referrals, access, engagement, follow-up and coordination of services
Ensure follow-up of tests, treatments, services and referrals incorporated into the client's plan of care
Accountable for engaging and retaining clients in care
Support adherence to treatment recommendations
Ensure that the plan of care is completed and updated and client progress notes are completed and submitted to supervisor within the designated time frame.
Orient clients to services available within the agency.
Document each client interaction comprehensively and concisely.
Advocate for client access of entitlement programs, treatment facilities, and other needed community services.
Promote client access into internal agency services including, but not limited to: support groups, housing services, daily bread, behavioral wellness, substance use treatment, and medical care.
Demonstrate developing knowledge of community resources.
Adhere to all government and funder regulations.

2. Miscellaneous
Requires the ability to relate to people of diverse backgrounds.
Responsible for maintaining confidentiality of all patients, clients, proprietary, and protected information.
Must be proficient in Microsoft Office; Word, Excel, Outlook and Explorer and have the ability to learn and navigate the HIT systems used
Excellent organizational and time management skills required.
Must have access to a reliable vehicle and meet the agency driving policy requirements for this position, including a valid NYS driver's license and proof of required automobile insurance for the vehicle used.
Employees are accountable for meeting performance standards of their departments. They participate in compliance audits and quality improvement plans.
Other duties as assigned.


Bachelor's degree in health, human or education services and a minimum of one year of qualifying experience including case management or casework OR an Associate degree in health or human services and two years of qualifying experience or certification as an R.N. or L.P.N. and two years of qualifying experience. Computer proficiency is required. Fluency in Spanish and/or ASL preferred.

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