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Care Manager of Health Home Care Management

Company: Sun River Health
Location: Bronx
Posted on: May 15, 2024

Job Description:

Job Description

Sun River Health a Federally Qualified Health Center system with over 40 locations, serving more than 245,000 patients throughout the Hudson Valley, New York City, and Long Island. Our belief stands firm: being healthy should not be a privilege for a few, but a right for all. As we move forward, we will continue to provide high-quality health care for everyone in our communities Our exceptional primary care practitioners, specialists, and support staff have made us a destination for affordable, high-quality care.

We are seeking a full-time reliable and talented Care Manager to join our Townsend site in the Bronx.

Must be flexible to some work in the field. This position is Full Time onsite Monday-Friday


The Health Home Care Manager provides care coordination and support to clients with chronic medical and behavioral health conditions that are also impacted by social determinants of health. Assists clients navigate social service, community, and healthcare systems.


Completes comprehensive assessments within the required timeframes. Maintains detailed, accurate and timely case notes. Conducts intakes as needed

Facilitates enrollment in Benefit and Entitlement programs. Develops linkages and refers patients for additional service supports

Provides timely and appropriate follow up on newly referred clients

Provides Health Home Care Management services at community-based locations and within the Sun River health centers

Facilitates periodic case record reviews and case conferences with all providers serving the client

Provides linkage, coordination with, referral to and follow-up with appropriate ongoing service providers, including mental health and medical specialists

Case conferences with interdisciplinary team including but not limited to PCP, substance abuse treatment team, residential, hospital discharge planners, etc., to coordinate care delivery between all linked providers and client

Conducts field work to meet their clients in the community

Maintains data and case records as required and prepares necessary reports

Develops, coordinates and integrates a coordinated care plan in cooperation with the client, the client's family, and/or the other providers serving the patient. Updates plan at specified intervals, and as needed based on changes in client's condition / circumstances

Performs and maintains effective care management for a caseload of clients, as assigned, from assessment to discharge

Tracks/ monitors client progress and produces/maintains detailed, accurate and timely case notes

Maintains updated case records through health home EMR, and coordinates effective electronic communication throughout all provider databases, as needed. Maintains case records in accordance with health home policies/procedures, agency standards and regulatory requirements

Participates and consults with team supervisor in case conferences, staff meetings, and discharge planning meetings to determine if client requires an alternate level of care or is appropriate for discharge


Bachelor's degree preferred in Health or Human Services related field with 2 years of related work experience. High School Diploma/GED required.

Job Type: Full-time

Salary: $23.00 - $28.75 per hour


Relation to Mission
The mission of Sun River Health is to increase access to comprehensive primary and preventive health care and to improve the health status of our community, especially for the underserved and vulnerable.

Equal Employment Opportunity
Sun River Health provides equal employment opportunities to all qualified individuals without regard to race, creed, color, religion, national origin, age, sex, marital status, sexual preference, or non-disqualifying physical or mental handicap or disability in each aspect of the human resources function.

Americans with Disabilities Act
Applicants as well as employees who are or become disabled must be able to perform the essential job functions either unaided or with reasonable accommodation. The organization shall determine reasonable accommodation on a case-by-case basis in accordance with applicable law.

Job Responsibilities
The following statements reflect the general duties, responsibilities and competencies considered necessary to perform the essential functions of the job and should not be considered as a detailed description of all the work requirements of the position. Sun River Health may change the specific job duties with or without prior notice based on the needs of the organization.

About Us

Sun River Health is a network of 43 Federally Qualified Health Centers (FQHCs) providing primary, dental, pediatric, OB-GYN, and behavioral health care to over 245,000 patients annually. With a dedicated staff of 2,000 doctors, nurses, and health care professionals, we pride ourselves on delivering high-quality, affordable care to those who need it most. Sun River Health started in 1975 when four African American mothers spearheaded efforts to open our first health center in Peekskill, New York to deliver accessible, high-quality, affordable services to patients in need - no matter their race, religion, income, or insurance status. Today, after 45 years of service, Sun River Health is still delivering on that promise to communities across the Hudson Valley, New York City, and Long Island.

Keywords: Sun River Health, Mount Vernon , Care Manager of Health Home Care Management, Executive , Bronx, New York

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