Health Home Care Manager - Adult OOD

Open Door Family Medical Center provides health care and wellness programs to individuals and families in need throughout Westchester, Putnam and Ulster Counties. A pioneer Federally Qualified Health Center, Open Door provides more than 300,000 patient visits annually and serves nearly 60,000 individual patients who might not otherwise have access. Open Door offers integrated services and a holistic approach to building healthier communities. Primary medical care, dental care, integrated behavioral health care, clinical nutrition, wellness programs, and chronic disease management are the foundation of its clinical programs.

Founded as a free clinic in 1972, Open Doors mission of building healthier communities through accessible, equitable, culturally competent health care has led to site and service expansions. Today, Open Door operates centers in Brewster, Mamaroneck, Mount Kisco, Ossining, Port Chester, and Sleepy Hollow, in addition to eight School-Based Health Centers in the Port Chester and Ossining School Districts, a mobile dental van in Mount Kisco, and a new dental practice in Saugerties, NY. For more information, please visit our website at www.opendoormedical.org.

Open Door is seeking a Health Home Care Manager in our Ossining, NY location.

Job Summary

Following the patient-centered medical home health care delivery model, the Health Home Care Manager participates in a patient-focused, team-based approach to provide direct and collaborative care coordination to Health Home members. As part of the medical care team, the services provided by the Health Home Care Manager aim to improve patient health outcomes and assist patients in taking control of their health care and becoming independent, and informed consumers of health care services. Primary responsibilities include assessing patients needs, developing care plans and engaging patients in medical services and the Health Home program.

Duties and Responsibilities

• Outreach individuals and engage them into the Health Home program
• Conduct annual assessments to identify Health Home enrollees individualized needs related to psychosocial wellbeing, physical health and the social determinants of health; utilize standardized assessment tools; monitor needs on an ongoing basis
• Based on the findings from the annual assessment, collaborate with Health Home enrollees to develop a plan of care
• Engage Health Home enrollees in the goal setting process and utilize Motivational Interviewing and other techniques to assist in goal achievement
• Coordinate and arrange for the provision of medical, behavioral health and other relevant services
• Accompany Health Home enrollees to appointments as needed; model and coach on medical/behavioral visit navigation with the aim of empowering Health Home enrollees to become independent, effective health care consumers
• Conduct home visits as needed
• Support Health Home enrollees in adherence to treatment recommendations from medical and behavioral health providers
• Provide psychoeducation using one-on-one teaching, written and printed materials as well as computer and video instruction approved by the primary care team to assist with Health Home enrollees understanding of physical and behavioral health conditions and treatments
• Identify available community-based resources and actively manages appropriate referrals, access, engagement, follow-up and coordination of services
• Promote evidence-based wellness and prevention by providing health education on chronic diseases such as diabetes, asthma, hypertension, and HIV/AIDS to improve adherence to prescribed treatment
• Link Health Home enrollees to services/resources based on individual needs and preferences such as peer support programs, support groups, smoking cessation, and self-management programs
• Discuss advance directives and health care proxies with enrollees and their families or caregivers
• Retain Health Home enrollees in care over time
• Maintain a caseload of 50 individuals
• Perform duties in accordance with established clinic policies and procedures, objectives, quality improvement activities, safety, environmental and infection control standards
• Travel as required to community based meetings, medical/behavioral health provider sites and meetings with Health Home enrollees
• Maintain electronic medical records in compliance with Open Doors standards
• Complete all documentation as required for the Health Home program
• Represent Open Door at community health fairs and community outreach activities
• Maintain documentation in compliance with Joint Commission standards and applicable city, state, and federal laws
• Participates in staff development programs, educational activities, seminars, and training opportunities

EDUCATION

• Masters Degree preferred; candidates with a Bachelors Degree and solid work experience will be considered as well
• Degree in Social Work or social sciences preferred; other degrees with relevant experience will be considered

SKILLS

• Fluent in English and Spanish
• Strong interpersonal skills including excellent active listening and clear oral communication skills
• Engaging, warm and caring personality
• Strong customer service, patient-centered orientation
• Empathetic and driven to assist patients
• Passionate about providing high quality care to low-income, under-served individuals and those lacking access to health care
• Able to function effectively as a member of an interdisciplinary team and committed to collaborative team-based care
• Able to navigate healthcare and community settings as well as patients natural settings (i.e. place of residence)
• Culturally competent/sensitive (racial, ethnic, linguistic, LGBTQ , physical ability, etc.) and committed to inclusive, multi-cultural programming
• Comfortable providing direct patient care to patients age 18 and older with chronic medical and behavioral health needs
• Proficient computer use, including Microsoft Office applications
• Strong writing and reading skills
• Able to understand and follow detailed instructions
• Highly organized and self-directed, able to multi-task
• Flexible and exhibits the ability to adapt as situations evolve
• Comfortable working in a fast-paced, high accountability environment
• Effective in problem solving and exhibits excellent judgment and the ability to prioritize

EXPERIENCE

• At least three years experience in healthcare and/or social services settings
• Health education experience is preferred
• Experience with electronic medical records is preferred
• Knowledge of/experience in case management and care coordination is preferred

REQUIREMENTS

• Must have valid NYS driving license and daily access to car

There are many fantastic benefits to a career at Open Door Family Medical Centers. In addition to working to effect positive change in the health and lives of thousands residents in our communities, Open Door offers its employees a stimulating, diverse and team-based work environment with comprehensive benefits including medical, dental, life insurance, flexible spending accounts, 401(k), generous paid time off, and educational assistance. Aside from excellent benefits, we offer a competitive salary and annual bonuses based on organizational and individual objectives.

At Open Door, we enjoy working in a team-based, patient-centered environment and value the benefits of a diversified workplace that values our patients and the communities we serve.

If you want to make a difference in the lives of thousands of patients and if this position speaks to your capabilities, experience and commitment to improve the health of our communities, please submit your resume and cover letter with salary requirements.

Open Door is an Equal Opportunity Employer