Care Manager of Health Home Care Management - The Hub

Sun River Health provides the highest quality of comprehensive primary, preventative and behavioral health services to all who see 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 serving communities in Suffolk, Rockland, Orange, Dutchess, Ulster, Sullivan, Columbia and Westchester County. Sun River Health is currently seeking a Full-time Care Manager to join our team in Bronx, NY at The Hub location.

The Care Manager has overall day-to-day responsibility for coordinating the activities of the care team for patients with complex medical and psychosocial needs and for facilitating each patient’s access to the full range of medical and psychosocial services in an efficient and effective manner.

Essential Duties and Responsibilities of a Care Manager

• 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.