TITLE: Care Manager
REPORTS TO: Program Director
DEPARTMENT: Health Home (Adult)
Position Summary:
Under the supervision and direction of the Adult Health Home Care Management Supervisor, Assistant Director, and Program Director, the Adult Health Home Care Manager is responsible for providing comprehensive, person-centered care management services to an assigned caseload of adult members. The Care Manager works directly with members, families and natural supports, healthcare providers, behavioral health providers, hospitals, specialists, community-based organizations, and other members of the care team to identify needs, coordinate services, address barriers to care, and support members in achieving meaningful health and life goals. This role requires more than providing referrals or information. The Care Manager is responsible for actively coordinating care, following services through to connection and outcome, identifying and addressing gaps in care, and ensuring members receive the medical, behavioral health, social, and community-based supports needed to improve health, stability, and overall well-being. Care Managers are expected to maintain active knowledge of their caseload, build meaningful relationships with members, respond to changing needs, collaborate across systems, and take ownership of required follow-up. Success in this role requires strong engagement skills, initiative, organization, professional judgment, accountability, and the ability to work independently while maintaining regular communication with supervisory and program leadership.
Key Responsibilities:
Member Engagement and Relationship Building
- Establish and maintain consistent, professional, and person-centered relationships with assigned members.
- Educate members and, when appropriate, their families or natural supports about the Health Home program and available services.
- Maintain regular and meaningful contact with members based on their needs, goals, level of risk, and program requirements.
- Complete comprehensive assessments and reassessments within required timeframes.
- Work collaboratively with members and their care teams to identify medical, behavioral health, social, functional, financial, educational, vocational, and other needs.
- Develop and maintain comprehensive, person-centered Plans of Care with meaningful and measurable goals.
- Monitor progress toward goals and update care plans as member needs, circumstances, and priorities change.
- Identify early signs of disengagement and initiate timely re-engagement efforts before closure is considered.
Comprehensive Care Coordination
- Serve as a central point of coordination across the member’s healthcare, behavioral health, social service, and community-based care team.
- Establish and maintain communication with primary care providers, behavioral health providers, hospitals, specialists, pharmacies, substance use treatment providers, residential programs, and other involved supports.
- Initiate and participate in case conferences and interdisciplinary care planning when needed.
- Identify and address gaps, duplication, and fragmentation in services.
- Support members in navigating healthcare and behavioral health systems, attending appointments, accessing medications, and following through with treatment recommendations.
- Provide timely follow-up after hospitalizations, emergency department visits, rehabilitation stays, and other significant transitions of care.
- Identify members who may benefit from specialized or higher levels of support, including HH+, CCBHC, substance use treatment, crisis services, and other internal or external programs.
- Advocate for members when barriers interfere with access to necessary care and services.
Health-Related Social Needs and Community Supports
- Assess and address needs related to housing, food insecurity, transportation, benefits, financial stability, employment, education, legal needs, social isolation, and other health-related social needs.
- Connect members to appropriate internal and external services based on their identified needs and preferences.
- Follow referrals through to connection, engagement, and outcome rather than providing information or referrals alone.
- Identify when a referral has not resulted in connection and work with the member to address barriers or identify alternative options.
Caseload Management, Retention, and Accountability
- Maintain active and current knowledge of all members assigned to the caseload.
- Organize and prioritize work based on member needs, risk, required deadlines, and program expectations.
- Track outstanding referrals, appointments, provider follow-up, documentation requirements, and other member needs through completion.
- Identify members who have not been contacted, have insufficient service activity, have overdue requirements, or require additional follow-up.
- Actively work to maintain member engagement and complete required re-engagement efforts before discharge or closure is pursued.
- Participate in advance discharge planning and support appropriate graduation from Health Home services when members have achieved their goals.
- Escalate member, service delivery, or operational barriers that cannot be resolved independently.
- Meet established expectations related to member engagement, service delivery, documentation, billing, productivity, and caseload management.
Documentation, Compliance, and Risk Response
- Complete all required documentation accurately and within established program and agency timeframes.
- Ensure documentation clearly reflects the member need addressed, service provided, care coordination activity completed, and planned follow-up.
- Complete required assessments, Plans of Care, progress notes, and other program records timely.
- Meet all applicable face-to-face, service delivery, billing, and productivity expectations.
- Maintain accurate member information in designated electronic health records and program systems.
- Respond timely to documentation corrections, quality reviews, and supervisory feedback.
- Identify and appropriately respond to changes in member risk, safety, health, or functioning.
- Immediately consult with supervisory leadership regarding urgent, high-risk, or complex situations.
- Report serious incidents, allegations of abuse or neglect, and other sensitive situations in accordance with agency and regulatory requirements.
- Maintain member confidentiality and comply with HIPAA, agency policies, Lead Health Home requirements, Medicaid requirements, and applicable regulatory standards.
Supervision, Training, and Program Participation
- Participate in required individual supervision with the assigned Care Management Supervisor on a weekly basis.
- Come prepared for supervision to discuss member needs, risks, barriers, progress, performance expectations, and cases requiring additional support.
- Maintain regular communication with the Care Management Supervisor and respond timely to direction from the Assistant Director and Program Director.
- Attend and actively participate in all required Adult Health Home meetings, case conferences, trainings, in-services, and professional development activities.
- Complete all mandatory agency, Health Home, Lead Health Home, regulatory, and role-specific trainings within required timeframes.
- Successfully complete the Adult Health Home program’s required 30/60/90-day onboarding process and established training, competency, and performance expectations.
- Collaborate with Health Home Intake and Outreach staff and other internal programs to support continuity of care and reduce duplication of services.
- Perform other related duties as assigned.
Work Environment, Travel, and On-Site Expectations
This is an in-person, community-based position requiring approximately 75% travel throughout the five boroughs of New York City to provide home and community-based services and coordinate care on behalf of members. Regular travel using public transportation is required. Care Managers are assigned two designated in-office days each week and are required to report on-site on those days. On designated field days, Care Managers with fewer than two scheduled home or approved community-based member visits are required to begin and end their workday at their assigned office location. Care Managers are expected to maintain an accurate and current schedule of all field-based activities and remain available and responsive to supervisory and program leadership during scheduled work hours.
Qualifications
- Bachelor’s degree in social work, psychology, human services, public health, sociology, healthcare, or a related field required.
- Minimum of two years of experience in care management, case management, healthcare, behavioral health, social services, or a related human services setting preferred.
- Experience working with individuals with chronic medical conditions, behavioral health needs, substance use needs, or complex social needs strongly preferred.
- Knowledge of Medicaid, healthcare and behavioral health systems, community resources, benefits, and health-related social needs preferred.
- Strong engagement, communication, organization, time management, and follow-through skills.
- Ability to manage multiple priorities and deadlines while maintaining accurate documentation.
- Ability to work independently in community settings and collaboratively as part of an interdisciplinary team.
- Comfort using electronic health records, databases, Google Workspace, Microsoft Office, and other required technology.
- Fluency in Spanish, Russian, Ukrainian, Haitian Creole, French, Mandarin, Cantonese, Yiddish, or Hebrew is strongly preferred.
Work Location: In-person/Field-Based
Salary Range: $29-$32/Hour
Job Type: Full Time
Schedule: 8 Hour Shift Monday through Friday
Benefits We Offer:
- Competitive salary based on experience.
- Medical, Dental, and Vision insurance.
- Up to 3% 401k Profit Sharing plan automatic contribution for eligible employees.
- Additional 4% 401k match of your contribution from your salary.
- Employee Assistance Program Services (EAP).
- Paid time off (PTO).
Interborough is an EEO employer and provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regards to race, color, religion, sex, national origin, disability status, genetics, protected veterans’ status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state and/or local law and encourage women, veterans and other minorities to apply. Interborough Developmental and Consultation Center is committed to Diversity, Equity, and Inclusion (DEI) in the workplace. We believe that DEI is to unite every community.
#IDCCCM
Pay: $29.00 - $32.00 per hour
Benefits:
- 401(k)
- Dental insurance
- Health insurance
- Vision insurance
Application Question(s):
- Are you fluent in any languages other than English? If so, which languages?
Education:
Experience:
- care/case management, healthcare, social or human services: 2 years (Preferred)
Work Location: In person
