Care Manager HHUNY Bilingual

This position will be based out of either our Sodus or Geneva Health Centers.

Position Summary:

The HHUNY Care Manager advocates for the social, physical, and mental well-being of individuals with chronic conditions. This role partners with patients to identify goals, coordinate services, and ensure collaboration among providers and community partners through the Health Homes of Upstate New York (HHUNY) program. The Care Manager serves as the central point of communication to promote integrated, patient-centered care and improved health outcomes.

Main Responsibilities:

Referral & Enrollment Process
• Educate eligible patients on the Health Homes of Upstate New York (HHUNY) program and services through phone and in-person outreach.
• Complete enrollment documentation and enter into the electronic health record and HHUNY system.
• Complete and review the HHUNY Comprehensive Assessment with the patient to ensure accuracy and completeness.
• Complete and submit a patient centered Plan of Care assessment within required post-enrollment timeframes.
• Collaborate with the patient to develop a patient care plan based on identified needs and goals.
• Ensure care plan goals follow the SMART framework (Specific, Measurable, Attainable, Relevant, and Timely).
• Complete a personalized crisis plan to reduce risk, promote self-management, and ensure the patient and care team are prepared to respond if a mental health crisis or safety concern arises.
Care Coordination
• Communicate the patient’s plan of care with providers, care managers, and external partners to ensure shared understanding of patient goals.
• Review care documentation to identify gaps or inconsistencies in treatment and collaborate with providers to address in alignment with the care plan.
• Maintain ongoing communication with the care team to align on updates, concerns, and progress toward patient goals.
• Participate in patient appointments or team meetings to remain informed on care progress and changes.
• Update the patient’s risk level monthly based on team input and patient interactions.
Patient Advocacy & Support
• Advocate for patient needs during appointments and interdisciplinary meetings.
• Review emergency and hospital discharge information to coordinate timely follow-up, medication reconciliation, and care transitions.
• Collaborate with the patient to establish preferred methods of communication and care management.
• Educate and empower patients on life skills and navigating the healthcare system as it relates to their care plan.
• Review care information with the patient post-visit to reinforce understanding and adherence.
• Coordinate or arrange transportation for specialty care appointments based on insurance eligibility, which may include direct patient transport when appropriate.

Documentation:

• Completes and submits monthly billing documentation and billing attestation through the HHUNY system.
• Reassesses the patient’s plan of care and safety plan annually or upon significant life changes.
• Complete biannual Continued Eligibility for Services assessment, to determine patient’s appropriateness for the HHUNY program.
• Record case details, demographics, services provided, and referrals in the electronic health record system and HHUNY systems.
• Address telephone encounters, actions, and referrals in the electronic health record system in accordance with Finger Lakes Community Health policies and procedures.
Other Duties
• Perform other related duties as assigned by the supervisor.

Physical Requirements:

• Sitting/Standing: Prolonged sitting with occasional standing or walking.
• Computer Use: Frequent typing and prolonged screen time.
• Light Lifting: Frequently lifting or carrying objects up to 15 pounds.
• Visual: Clear vision for reading and inspections.
• Hearing Clarity: Ability to hear conversations in person or in virtual communications.
Work Environment
• Health Center/Clinic: Work within a healthcare facility, interacting with patients and staff.
• Outreach: Outreach work within community and field setting, engaging with underserved and at-risk communities.
• Remote: Home or remote office, using virtual communication to collaborate and interact with patients and staff.
• Moderate-Paced: Dynamic environment that requires both productivity and accuracy to reach goals and project objectives.
• Office Hours: Standard business hours, with occasional extended shifts based on clinic needs.
• On-Call Hours: Outside of standard office hours, including evenings, weekends, and holidays to respond to urgent needs. Schedule determined by department needs.

Education:

• High school diploma or equivalent is required.
• Associate or bachelor’s degree in social work, public health, human services, or other related field is preferred.
Care Manager, HHUNY

Qualifications:

• 3+ years in a healthcare or customer service setting, functioning at an independent level with solid foundation of role knowledge required.
• A valid government-issued photo identification document is required.
• A valid New York State driver’s license in compliance with FLCH driver’s policy is required.
• Current New York State automobile insurance in compliance with FLCH underwriting agreement is required.
• Policy limits should reflect $100,000/$300,000/$100,000 coverage.
• Serves as a resource and educates on effective outreach and support programs.
• Has advanced expertise in facilitating team communication and conflict resolution.
• Applies advanced reasoning in complex situations to bring solutions to team.
• Applies advanced expertise to identify complex and recurring challenges.