Health Home Care Manager - Adult

Open Door is seeking a Health Home Care Manager to be based in Ossining, NY reporting to the Care Coordination Programs Manager. This position will work with children and their families with Medicaid who have chronic medical and behavioral health conditions to improve health outcomes, develop self-management skills and reduce unnecessary emergency room / hospital visits. The Care Manager will implement assessments, work with enrollees to establish care plan goals, provide health education and assist with coordination of medical and social services. The main location for this position is Ossining, NY with travel to other Open Door and community locations to provide services. The Care Manager reports to the Manager of Care Coordination Programs. For more about the New York State Health Home program, please see : care / medicaid / program / medicaid health_homes / Hours : Monday - Friday 8 : 30am - 4 : 30pm.Responsibilities : Outreach individuals referred to the program and engage them into the program. Conduct assessments to identify individualized needs related to psychosocial well-being, physical health and the social determinants of health. Based on the findings from the assessment, collaborate with enrollees to set goals and develop a care plan; monitor goal achievement and revise the care plan. Utilize Motivational Interviewing and other techniques to assist in goal setting and achievement. Coordinate and arrange for the provision of medical, behavioral health, social and other relevant services, including appointment scheduling, appointment reminders and transportation booking. Accompany enrollees to appointments both on- and off-site. Collaborate with family members / caregivers as well as internal and external service providers. Model and coach enrollees on medical / behavioral service navigation with the aim of empowering enrollees to become independent, effective health care consumers. Conduct home visits to provide services to enrollees and assess the enrollees living environment. Support enrollees in adherence to treatment recommendations from medical and behavioral health providers. Provide health education to assist with enrollees understanding of physical and behavioral health conditions and treatment and link enrollees with evidence- and research-based resources. Discuss advance directives and health care proxies with enrollees and their families or caregivers. Retain enrollees in care over time. Maintain a caseload of 50 individuals. Complete all documentation as required including data entry into New York State data portal and Open Doors electronic medical record. Qualifications : Bachelors Degree and relevant work experience. Degree in Social Work or social sciences preferred; other degrees will be considered. Fluent in English and Spanish is required. Minimum two years experience in healthcare and / or social services settings; case / care management experience a plus. Must have valid NYS driving license and daily access to car. Proficient computer use including MS Office applications, especially Excel; experience with electronic health records or case management software a plus. Must have valid New York State drivers license and daily access to a car. Strong written and verbal communications skills. Passionate about providing high quality care to low-income, under-served individuals and those lacking access to health care. Patient-centric, engaging and empathetic with strong active listening skills. Comfortable providing direct patient care to adults of all ages with an array of chronic medical and behavioral health needs.