Sun River Health provides the highest quality of comprehensive primary, preventative and behavioral health services to all who seek it, regardless of insurance status and ability to pay, especially for the underserved and vulnerable. Sun River Health is a Federally Qualified, Non-Profit Health Center.
We are seeking a reliable and talented Care Manager to join our Brooklyn Church Avenue Health Home Team.
· Works closely with the interdisciplinary care team including the PCP, mental health provider, residential services, substance abuse provider, etc. in the development and ongoing coordination of the care plan.
· Works closely with the Patient Navigator to direct field activity as needed and ensure the flow of information across and between the care team is optimized.
· Provides input to providers/patient/family for written individualized care plans.
· Reviews patient intake assessments and uses results to coordinate the completion of the care plan, self-management goals and strategies.
· In conjunction with the patient, identifies potential barriers to care and helps patient identify ways to overcome those barriers; reaches out to patients who have not met treatment goals to resolve barriers/adjust goals when possible.
· Evaluates medication compliance and assesses potential barriers to adherence; ensures medication reconciliation is current.
· Receives alerts to inpatient and ER admissions. Visits patients during inpatient stays and participates actively in discharge planning and care transition activities.
· Contacts patients after discharge from inpatient services and ER within one business day.
· Reaches out to patients to help them keep scheduled appointment; arranges for appropriate metabolic and periodic preventive screening in accordance with agency policy.
· Ensures that patients and care givers are aware of test results by facilitating discussions between the patient and physician as necessary.
· Coordinates services between patient and extended care team providers to ensure that integrated care plan is fully implemented.
· Regularly reviews workload report in TREAT to identify patients requiring, assessments outreach and engagement.
· Provides or arranges for provision of self-management/ wellness education, peer and other support groups in the language that the patient/family prefers.
· Organizes and participates in case conferences as per patient need and in accordance with agency policy
· Reviews benefits, entitlements, housing with the patient/family and assists in the application process. Follows up as necessary to ensure services are approved.
· Utilizes the TREAT system to complete all documentation and assessments timely including scheduling of all activity.