307 West 38th Street
The Care Manager 2 has the overall day-to-day responsibility for the coordination and delivery of Health Homes services including: comprehensive case management, care coordination and health promotion, comprehensive transitional care from inpatient to other settings, individual and family support, referral to community and social support services, and the use of health information technologies.
Essential Job Functions
The following duties are mandatory requirements of the job:
- Orients and educates clients and sometimes their families by meeting them; explaining the role of the care manager; initiating the care plan; providing educational information in conjunction with direct care providers related to treatments, procedures, medications, and continuing care requirements.
- Performs and reviews client intake assessment and uses results to coordinate the completion of the care plan, self-management goals and strategies; documents them in EMR.
- Interviews clients to assess client needs, prioritize needs, identify barriers in addressing needs, and strategize to overcome barriers.
- Works closely with the interdisciplinary care team including PCP, psychiatrist, therapist, residential services, substance abuse treatment program, ACT Team, etc.
- Develops interdisciplinary care plan and other case management tools by participating in meetings; coordinating information and care requirements with other care providers; resolving issues that could affect smooth care progression; fostering peer support; providing education to others regarding the case management process.\
- Monitors delivery of care by completing patient rounds; documenting care; identifying progress toward desired care outcomes; intervening to overcome deviations in the expected plan of care; reviewing the care plan with clients in conjunction with the direct care providers; interacting with involved departments to negotiate and expedite scheduling and completion of tests, procedures, and consults; reporting personnel and performance issues to the unit manager; maintaining ongoing communication with utilization review staff regarding variances from the care plan or transfer/discharge plan.
- Evaluates outcomes of care with the interdisciplinary team by measuring intervention effectiveness with the team; implementing team recommendations.
- Complies with hospital and legal requirements by fostering nursing practices that adhere to the hospitals and nursing division's philosophy, goals, and standards of care; requiring adherence to nurse practice act and other governing regulations.
- Respects clients by recognizing their rights; maintaining confidentiality.
- Maintains quality service by establishing and enforcing organization standards.
- Maintains client care database by entering new information as it becomes available; verifying findings and reports; backing up data.
- Maintains professional and technical knowledge by attending educational workshops; reviewing professional publications; establishing personal networks; benchmarking state-of-the-art practices; participating in professional societies.\
- Performs HARPs assessment; has and active HCS account and is trained in conducting NYS Community Mental Health
- Conducts home visits and participates in client appointments and case conferences in the community with other providers including HIV primary health care and treatment providers.
- Researches community resources and government benefit programs to determine eligibility criteria, provide appropriate referrals, and perform follow up activities for referrals.
- Receives alerts to inpatient and ER admissions of targeted patients , visits patients during inpatient stays and participates actively in discharge planning and care transition activities; and contacts patients on the day of discharge from inpatient services and ER or within 24 hours
- Proactively identifies or forecasts barriers clients will face in meeting goals and strategies to minimize or eliminate the barrier.
- Outreaches to clients to facilitate keeping scheduled appointments; arranges for metabolic and periodic preventive screening, per evidence based guideline standards
- Ensures that clients and care givers are aware of test results by facilitating a discussion between the client and physician as necessary
- Coordinates services between clients and extended care team providers to ensure that integrated care plan is fully implemented
- Regularly reviews patient information from care team members to identify patients requiring outreach and engagement.
- Assigns daily tasks to care navigator meet the needs of the caseload and the program. Advises supervisors of tasks which are not completed on time.
- Advocates overcoming barriers in accessing or maintaining services, and coordinates services with internal and external providers.
- Teaches clients through behavior modeling the necessary skills to promote self-sufficiency, medical adherence, and the ability to access community resources on their own
- Complies with the quality and productivity standards of GMHC and funding entities.
Education and Certification
- Bachelor’s degree in social work/psychology or other related human services field.
- A NYS teacher’s certificate for which a Bachelor’s degree is required; or
- NYS licensure and registration as a Registered Nurse and a bachelor’s degree; or
- A Bachelor’s level education or higher in any field with five years of experience working directly with persons with behavioral health diagnoses;
- A Credentialed Alcoholism and Substance Abuse Counselor (CASAC).
Special Skills and Knowledge
In addition to the above-listed job responsibilities and educational requirements, the ideal candidate for this position possesses most or all of the following:
- 2 years’ experience in case management working with PLWA
- Ability to make data entries into computer database,
- Knowledge of resources for PWAs and their support networks.
- Good verbal, written, computer, communication and interpersonal skills.
- Use of computer software --Microsoft Office Suite including Word and Outlook calendaring, and Excel.
Level of Language Proficiency
Bilingual fluency in English and Spanish preferred.
Minimum Education Required
How To Apply
When applying, please include both cover letter and resume.
For other opportunities at GMHC, visit our careers' site: http://gmhc.org/get-involved/careers