Health Home Care Manager

HEALTH HOME CARE MANAGERAre you looking for your next job opportunity? Try Jordan Health! Anthony L. Jordan Health Corporation is a trusted community health center throughout the Greater Rochester, NY area. As one of the first 5 Federally Qualified Health Centers (FQHC) established in the nation, its roots are steeped in service to those who face health and health care barriers, meeting their need for comprehensive medical, dentistry, behavioral health, and community services. Jordan Health is seeking a Health Home Care Manager an individual, working in conjunction with a care team to identify and proactively manage the care needs of high risk patients within the Federally Qualified Health Center practice setting. The Care Manager provides assessment, care coordination, advocacy and coaching for identified patients including patients participating in the Medicaid Health Home Program. The Care Manager uses established criteria to identify at-risk patients, and determines the drivers of risk in conjunction with the patient, family, physician and ancillary health care providers. An integral, professional member of the practice''s care team, the Care Manager measures the impact of care coordination interventions, and regularly re-assesses the patient''s risk for incurring adverse health outcomes.We welcome referrals. Interested parties can click here: to learn more about the position or share this opportunity.The Health Home Care Manager will ensure that: Provides care management services under the direction of the practice manager or provider: Identify or work with others to identify patients with high risk of adverse health outcomes Establish trusting relationships with patients enabling effective intervention and support. Conduct assessments of patient condition, needs, preferences and clinical and psychosocial barriers. Support the patient in identification of actionable goals to optimize health outcomes. Develop a plan of care that promotes improved health care outcomes and quality of life informed by the patient''s goals, strengths and barriers. Implement the patient approved plan of care in collaboration with the patient through the practice''s care team, community- and home-based visits and telephonic support: Provide comprehensive care management including self-management support, health promotion, connection/referral to appropriate physical, mental health, or substance abuse providers as well as community-based organization social supports to decrease the barriers preventing the patient from attending appointments and following the plan of care; • Utilize self-management support interventions to promote self-advocacy. Monitor the patient''s level of activation relative to their health goals over time. • Advocate for patients to ensure access and timely service delivery across the continuum of care and community resources.• Provide patients/caregivers with information in support of care plan goals. • Optimize patient access to needed services through insurance and other benefits. Facilitate care coordination with primary or specialty medical care as well as acute and outpatient/inpatient medical, mental health and substance abuse services, and other care managers involved in supporting the individual; Provide culturally competent interventions based on patient assessment and identified cultural needs. Provide comprehensive transitional care with an emphasis on coordination of care and services post- critical events;Work with the attending/consulting physicians to facilitate effective transitions through timely communication of information necessary for patient care and discharge planning, and supporting appropriate patient self-management. Develop an intervention plan that addresses events such as emergency department visits, inpatient admissions or other crisis events to ensure planned crisis interventions are effective and result in necessary modifications to the plan of care and addresses potential need for additional support services; Provide patient education; Facilitate solutions to patient care delivery problems; Work with family regarding the patient''s needs; assess caregivers'' burdens; provide support to family and caregivers; Ensure language access/translation capability. § Review patient progress no less frequent than quarterly. § Modify goals and care management interventions as appropriate to the needs/progress of the individual. § Share information (e.g. progress, barriers, new conditions) with practice care team members and other care providers. § Participate in patient care team meetings. § Meet practice policy and procedures related to documentation through a software tool of care management activities and their effectiveness. § Handle confidential information in accordance with HIPAA as well as state and federal privacy and confidentiality rules. Participates as a member of the care team: § Participates effectively as a care team member within the practice: Foster a positive working relationship with patients, providers and practice staff; Work effectively with others to coordinate patient and access care support services; Provide input relating to changes that may enhance the practice effectiveness; Participate in meetings and huddles as appropriate; Provide feedback to providers regarding patient progress and barriers encountered; Prepare for and participate in case review meetings to share cases, discoveries, concerns and collaborate in the development of plans of care EDUCATION AND EXPERIENCE REQUIRED: Minimum Education: BSW/Human Services or other related field with 5 years care management experience. ? Excellent communication skills and ability to form collaborative partnerships across all service settings. ?Bilingual preferred. ? Working knowledge of the provision of health care in a variety of settings. LICENSES AND CERTIFICATIONS: Valid driver''s license SPECIAL SKILLS, KNOWLEDGE REQUIRED: o Bilingualo Excellent communication skills o Ability to form collaborative partnerships across all service settings. o Working knowledge of the provision of health care in a variety of settingBenefits: Jordan Health offers a competitive salary and full benefits offering including medical, dental, vision, life insurance, and a 403b retirement plan. We offer a Professional Development allowance. Please Send Resume to: Human Resources, Anthony L Jordan Health Corp., 214C Lake Ave, Rochester, NY 14608or FAX 585.423.2853 Jordan Health offers equal opportunities to all persons without regard to race, color, religion, age, sex, disability, national origin, ancestry, citizenship, military or veteran status, marital status, sexual orientation, domestic violence victim status, predisposing genetic characteristics, or genetic information, or any other status protected by law. About Jordan Health:Jordan Health is an independent FQHC, with Level III Patient-Centered Medical Home (PCMH) designation through the National Committee on Quality Assurance. Jordan Health receives funding from the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services. Jordan Health is a network of outpatient primary care offices with providers who follow a panel of patients. While independent, Jordan Health actively collaborates with the major hospital and healthcare systems in our operating area to provide a total safety net of healthcare PLIANCE: This position requires compliance with Jordan Health''s Compliance Program, compliance Code of Conduct, and its written policies, procedures, and protocols (collectively, the ''Written Standards''). Such compliance will be an essential element considered as part of the regular performance evaluation of the Compliance Database Librarian. Failure to comply with the Written Standards (which includes the failure to report any conduct or event that potentially violates legal or compliance requirements of the Written Standards) will be met by the enforcement of disciplinary action, up to and including possible termination of employment, in accordance with Jordan Health''s Compliance Program Policy and Procedure - Addressing Instances of Non-Compliance Through Appropriate Disciplinary Actions .RequirementsSame as Above

Created: 2026-04-04