Health Home Care Manager - Adult PCOD

Open Door Family Medical Center provides health care and wellness programs to individuals and families in need throughout Westchester, Putnam and Ulster Counties.

A pioneer Federally Qualified Health Center, Open Door provides more than 300,000 patient visits annually and serves nearly 60,000 individual patients who might not otherwise have access.

Open Door offers integrated services and a holistic approach to building healthier communities. Primary medical care, dental care, integrated behavioral health care, clinical nutrition, wellness programs, and chronic disease management are the foundation of its clinical programs.

Responsibilities :

• Outreach individuals referred to the program and engage them into the program.
• Conduct assessments to identify individualized needs related to psychosocial well-being, physical health and the social determinants of health.
• Based on the findings from the assessment, collaborate with enrollees to set goals and develop a care plan; monitor goal achievement and revise the care plan.
• Utilize Motivational Interviewing and other techniques to assist in goal setting and achievement.
• Coordinate and arrange for the provision of medical, behavioral health, social and other relevant services, including appointment scheduling, appointment reminders and transportation booking.
• Accompany enrollees to appointments both on- and off-site.
• Collaborate with family members / caregivers as well as internal and external service providers.
• Model and coach enrollees on medical / behavioral service navigation with the aim of empowering enrollees to become independent, effective health care consumers.
• Conduct home visits to provide services to enrollees and assess the enrollees’ living environment.
• Support enrollees in adherence to treatment recommendations from medical and behavioral health providers.
• Provide health education to assist with enrollees’ understanding of physical and behavioral health conditions and treatment and link enrollees with evidence- and research-based resources.
• Discuss advance directives and health care proxies with enrollees and their families or caregivers.
• Retain enrollees in care over time.
• Maintain a caseload of 50 individuals.
• Complete all documentation as required including data entry into New York State data portal and Open Door’s electronic medical record.
16 days ago