Sun River Health
Care Manager of Health Home Care Management
Sun River Health provides comprehensive primary, preventative, and behavioral health services to all who see it, regardless of insurance status or ability to pay, especially the underserved and vulnerable. We are a Federally Qualified, Non-Profit Health Center serving communities in Suffolk, Rockland, Orange, Dutchess, Ulster, Sullivan, Columbia and Westchester County. We are seeking a full-time Care Manager to join our team in Westchester Square.
Responsibilities
Work closely with the interdisciplinary care team—including the PCP, mental health provider, residential services, substance abuse provider, and others—to develop and coordinate the care plan.
Collaborate with the Patient Navigator to direct field activity as needed and ensure the flow of information across the care team.
Provide input to providers, patients, and families for written individualized care plans.
Review patient intake assessments and use results to coordinate completion of the care plan, self‑management goals, and strategies.
Identify potential barriers to care and help patients find ways to overcome them; reach out to patients who have not met treatment goals to resolve barriers or adjust goals when possible.
Evaluate medication compliance, assess potential barriers to adherence, and maintain current medication reconciliation.
Receive alerts to inpatient and ER admissions, visit patients during inpatient stays, and participate actively in discharge planning and care transition activities.
Contact patients after discharge from inpatient services and ER within one business day.
Reach out to patients to help them keep scheduled appointments; arrange for appropriate metabolic and periodic preventive screenings in accordance with agency policy.
Ensure that patients and caregivers are aware of test results by facilitating discussions between the patient and physician as necessary.
Coordinate services between patients and extended care team providers to ensure the integrated care plan is fully implemented.
Regularly review workload reports in TREAT to identify patients requiring assessment, outreach, and engagement.
Provide or arrange for self‑management/wellness education, peer and other support groups in the language preferred by the patient/family.
Organize and participate in case conferences as per patient needs and in accordance with agency policy.
Review benefits, entitlements, and housing with the patient/family and assist in the application process, following up as necessary to ensure services are approved.
Utilize the TREAT system to complete all documentation and assessments in a timely manner, including scheduling of all activities.
Qualifications
Minimum Education:
High School diploma or GED.
Preferred Education:
Bachelor's degree in Health or Human Services or related field.
Minimum Experience:
2 years of related work experience.
Job Type:
Full-time
Salary:
$23.00 - $26.00 per hour
Mission Alignment The mission of Sun River Health is to increase access to comprehensive primary and preventive health care and to improve the health status of our community, especially for the underserved and vulnerable.
Equal Employment Opportunity Sun River Health provides equal employment opportunities to all qualified individuals without regard to race, creed, color, religion, national origin, age, sex, marital status, sexual preference, or non‑disqualifying physical or mental handicap or disability in each aspect of the human resources function.
Americans with Disabilities Act Applicants as well as employees who are or become disabled must be able to perform the essential job functions either unaided or with reasonable accommodation. The organization shall determine reasonable accommodation on a case‑by‑case basis in accordance with applicable law.
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Responsibilities
Work closely with the interdisciplinary care team—including the PCP, mental health provider, residential services, substance abuse provider, and others—to develop and coordinate the care plan.
Collaborate with the Patient Navigator to direct field activity as needed and ensure the flow of information across the care team.
Provide input to providers, patients, and families for written individualized care plans.
Review patient intake assessments and use results to coordinate completion of the care plan, self‑management goals, and strategies.
Identify potential barriers to care and help patients find ways to overcome them; reach out to patients who have not met treatment goals to resolve barriers or adjust goals when possible.
Evaluate medication compliance, assess potential barriers to adherence, and maintain current medication reconciliation.
Receive alerts to inpatient and ER admissions, visit patients during inpatient stays, and participate actively in discharge planning and care transition activities.
Contact patients after discharge from inpatient services and ER within one business day.
Reach out to patients to help them keep scheduled appointments; arrange for appropriate metabolic and periodic preventive screenings in accordance with agency policy.
Ensure that patients and caregivers are aware of test results by facilitating discussions between the patient and physician as necessary.
Coordinate services between patients and extended care team providers to ensure the integrated care plan is fully implemented.
Regularly review workload reports in TREAT to identify patients requiring assessment, outreach, and engagement.
Provide or arrange for self‑management/wellness education, peer and other support groups in the language preferred by the patient/family.
Organize and participate in case conferences as per patient needs and in accordance with agency policy.
Review benefits, entitlements, and housing with the patient/family and assist in the application process, following up as necessary to ensure services are approved.
Utilize the TREAT system to complete all documentation and assessments in a timely manner, including scheduling of all activities.
Qualifications
Minimum Education:
High School diploma or GED.
Preferred Education:
Bachelor's degree in Health or Human Services or related field.
Minimum Experience:
2 years of related work experience.
Job Type:
Full-time
Salary:
$23.00 - $26.00 per hour
Mission Alignment The mission of Sun River Health is to increase access to comprehensive primary and preventive health care and to improve the health status of our community, especially for the underserved and vulnerable.
Equal Employment Opportunity Sun River Health provides equal employment opportunities to all qualified individuals without regard to race, creed, color, religion, national origin, age, sex, marital status, sexual preference, or non‑disqualifying physical or mental handicap or disability in each aspect of the human resources function.
Americans with Disabilities Act Applicants as well as employees who are or become disabled must be able to perform the essential job functions either unaided or with reasonable accommodation. The organization shall determine reasonable accommodation on a case‑by‑case basis in accordance with applicable law.
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