Case Manager

Description: The Care Manager (CM) works with Medicaid Health Home clients with complex healthcare needs, and responsibility for overall management of a caseload of approximately 25-30 clients.

Responsibilities: Responsible for the overall caseload management and case management team service delivery. Conduct comprehensive assessments or reassessments inclusive of medical, behavioral, rehabilitative and long-term care and social service needs. Develop and implement individualized patient-centered care plans to identify the member's needs and goals and include family members and other social supports as appropriate. Case conference with a primary care physician and/or specialists and other care team members identify and involved in the member's care plan. Refer and link the client to needed services to support care plan goals, including medical/behavioral health care, patient education and self-help/recovery and self-management. Following up with the hospital or ER upon notification of a client's admission and/or discharge. Facilitating discharge planning from an ER, hospital, residential or rehabilitative setting to a safe transition/discharge where care needs are in place. Coordinate the provision of services including as per their acuity level. Support adherence to treatment recommendations. Monitor and evaluate a client's needs, including prevention, wellness, medical, mental health, care transitions, and social and community services as appropriate. Complete all required internal and external trainings. Adhere to agency personnel policies, expectations and professional requirements. Qualifications, Experience & Requirements

Education: Bachelor's degree and/or CASAC certification.

Experience: 2 years case management, care coordination or case management experience, working in community-based programs. Experience working with Medicaid, chronically ill and/or functionally challenging populations.

Technical skills: computer literacy, EMR/database familiarity, proficiency/familiarity with mobile technology. Cultural competence: awareness of and ability to work non-judgmentally with diverse and culturally complex populations. Interpersonal skills: critical thinking skills, writing and oral communication skills; energetic and positive approach to working with in an evolving and challenging environment.

Travel: ability and willingness to travel throughout NYC.

Language: bi-lingual (English/Spanish) preferred.