Population Health Care Manager (Full-Time)

HHHN Mission To provide the best health care, and access to that care, for everyone in our communities HHHN Vision To pioneer an innovative, sustainable and community-focused health system through comprehensive primary care and diverse partnerships Proposed Schedule: 40 hours per week. Monday-Friday 8am-4:30pm. Position Summary: The Population Health Care Manager is an integral part of the patient’s care team, enhancing primary care and providing an array of services to the patients of the network and support to the primary/specialty care settings. These services include but are not limited to education, coordination, coaching, transfer of self-management skills, and addressing barriers (including socio-economic). Guidance will be provided to the patients and families for the purpose of improving the health of our populations, promoting positive transitions of care, improving the quality of care provided and decreasing overall costs. Care management activities will primarily take place via telehealth, in the home, hospital, community setting, and occasionally in the health center. Essential Duties and Responsibilities: In collaboration with the embedded care managers, review daily hospital discharge information and risk assessments to identify appropriate patients that would benefit from a home visit and program enrollment (transitions, CCM, Health Home, etc.) Work with embedded care managers to identify patients that would benefit from a home or community visit to meet their current care management care plan goals Provide coaching, information, and referral services to patients managing various chronic health conditions via telehealth, health center, and/or in a home setting Identify and address gaps in care and/or services to provide relevant community and/or health care resources. Develop individualized, goal-oriented, patient-centered care plans that promote positive outcomes and address physical health, mental health, and socio-economic barriers. Promote patient self‐management and empower patients and/or families to achieve maximum levels of wellness and independence Maintain ongoing communication between the patient and health center care team Sustain an ongoing responsibility for assigned caseload by prioritizing referrals and activities according to intensity, needs and required follow-up. Demonstrate efficient time management through accurate and timely documentation of care interventions, in‐home visits, and follow up calls Build and maintain efficient and effective relationships with external organizations, including but not limited to home care agencies, hospitals, and external specialty providers that support a positive outcome for patients Work closely with the care management team and build effective relationships among care team members that support a positive outcome for patients Complete annual care management competencies and any other relevant competencies/trainings as needed. Recognize the patient as a contributing member of the clinical team Provide any other services as directed by HHHN to ensure proper care and treatment to the patient and/or families. Adhere to the guidelines as set forth in the Networks Remote Work Program and Expectations policy on the HWEB Enthusiastically support the Mission, Vision, and Core Values of Hudson Headwaters Health Network. Perform additional duties and special projects as assigned Qualifications: RN degree or LPN Certification with active NYS Nursing License in good standing required 2-4 years of professional experience in case (care) management, social work, or health care coaching preferred Current BLS certification Must have and maintain a valid driver license and be able to travel throughout the Network Must have strong verbal and written communication skills Proficient computer skills including Microsoft applications and electronic medical records Must be well organized and can effectively manage multiple cases and projects Must be self-directed, detail-oriented, and motivated Must be able to work independently as well as collaborate and communicate effectively with colleagues, supervisors, service delivery partners, other health care professionals and co-workers to build and maintain effective dynamic professional team relationships The pay rate for this position is $36.00/hour.