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Help families find the help they need! JOB IS IN QUEENS - REMOTE AND ON THE FEILD Work with families and navigate the Medicaid system with them. Help them find housing, mental health services, occupational health services, and all other New York programs. This job is partly remote and partly on the field. You'll be going to families' homes and speaking with them about what services they may need, helping them find those services, and helping refer them over too! Job duties: - Complete initial and annual comprehensive assessment of medical, behavioral health, and social service needs for the assigned health home enrollees. - Provide disease-specific education and information regarding community resources. - Collaborate with a variety of community providers and resources to obtain needed services and support, utilizing community and family resources to create a sustainable support system. - Request and coordinate team and patient meetings as needed or requested by patient/family and/or team and/or escalate care management when medical assessment is needed. - Ensure that diagnostic, post-hospitalization, and specialty referrals have been executed and that results received and acted upon as needed. - Document plan of care, patient utilization, activities, and other required information with the State and EMR. - Monitor assigned enrollees' utilization of services, ensuring care is accessible, attended, and effective. - Provide regular data to the team on patient compliance and strategies to improve patient compliance. - Participate in on-call activities as directed/scheduled by the Program Coordinator. - Participate in regularly scheduled team meetings as prescribed by the practice's policy. - Participate in cultural competency events and training appropriate to job duties. - Frequent non-medical management coaching, education, follow-up visits, and phone calls to patients to monitor progress and identify new barriers or concerns. - Assisting with financial or other social issues that may provide barriers to patient compliance - Providing education/guidance to patients and family on tools to manage chronic illnesses, developing individual and web-based tools and resources to improve compliance. - Identifying and connecting patients with community resources to assist with improving compliance with treatment protocols and social issues (e.g. legal aid). - Accurately and timely document all interventions into prescribed electronic medical record systems to ensure timely reimbursement in compliance with New York State Health Home regulations and Patient-centered medical home regulations. - Participate in patient/outpatient care training regarding the care management strategies for difficult-to-manage patients, and educate office staff on patient or office system issues, including communicating patient care inconsistencies between the primary care physician and referring specialists. Job Qualifications - The Health Home Care Manager must have a BA and a minimum of 2 years of relevant experience in Human Care Services. - Excellent communication and team skills, including the ability to form strong collaborative interdisciplinary partnerships across care settings. - Sound computer knowledge and skills, including an aptitude for using health information technology to guide activities. - Ability to work independently and meet deadlines. Creativity and strong organizational skills. - Valid NYS driver's license including access to reliable transportation that enables fulfillment of the position's travel requirements
Bronxworks helps individuals and families improve their economic and social well-being. From toddlers to seniors, we feed, shelter, teach, and support our neighbors to build a stronger community. In all aspects of our work, we strive for the highest ethical and performance standards and is guided by the belief that people are to be treated with dignity and respect regardless of their present situation or past experiences. We have 37 locations throughout the borough providing a variety of programs that offer assistance in the areas of family, children and youth support, educational services, elder care, homelessness, mental health and workforce development. We are an employer of choice for anyone interested in a meaningful career in the social services field. RESPONSIBILITIES Provide direct services to clients, including intake, engagement, assessment, referral, service plan development and follow-ups. Attend monthly Community board, NYPD and other stakeholder’s meetings to promote program, center activities or events. Monitor and recruit interns and volunteers Monitor and document client progress toward service plan goals. Will increase Pyramid Community Service Program community engagement and assist Director with creating engaging programming to enhance Pyramid Community Service Program awareness. Will conduct in-house audits on files and facility to make sure we complies with DOH and DYCD. Document all interactions with, or on behalf of, clients. Build community partnerships to strengthen center’s community resources. Provide general clerical support, including filing, faxing, word processing, typing, photocopying, and data entry. Answer telephones, take messages and direct calls to the appropriate parties. Report to, and meet with, supervisor on a monthly basis. Complete program reports on a monthly basis or more frequently as required. Assist with special projects as required. Perform additional duties as assigned by Director. QUALIFICATIONS High School diploma or equivalent credential required. A minimum of 1-years of relevant work experience. Proficiency in English required; proficiency in a second language preferred. Strong oral and written communication, time management and organizational skills are necessary. Proficiency in Microsoft Office suite and other standard business technology is required. PHYSICAL REQUIREMENTS Ability to use a computer for prolonged periods. Ability to occasionally lift and/or move up to 10 pounds. Ability to stand, walk, or sit for long periods of time. Ability to climb five flights of stairs, if required to conduct home visits and/or fieldwork. Ability to bend and retrieve objects and/or documents. Ability to travel in the boroughs of New York City and its adjacent counties via public transportation. Ability to travel for a minimum of 1 mile within a reasonable amount of time and in all types of weather, including inclement weather, if required to conduct home visits and/or field work. BronxWorks seeks to build an inclusive organization grounded in respect for differences. We support all aspects of diversity, and in accordance with federal, state and local laws, does not discriminate unlawfully against employees and applicants for employment on the basis of age, color, creed, disability, marital status, military status, national origin (including ancestry), predisposing genetic characteristic, race, sex, gender, actual or perceived sexual orientation (including actual or perceived heterosexuality, homosexuality, bisexuality and asexuality), status as a victim of domestic violence, or any other characteristic protected by law. This commitment applies to all terms, conditions and privileges of employment, including but not limited to recruitment, hiring, compensation, training and employee development, placement, promotion, demotion, upgrading, downgrading, transfer, layoff and termination.