Description and Requirements The Field Based Care Manager evaluates members’ care needs and promotes quality outcomes and treatment via a variety of modalities and engagement strategies. The Field Based Care Manager works directly with members in field-based settings and telephonically to support members’ unique care needs and successful engagement outcomes with members and treatment providers. The Field Care Manager also works directly with hospital clinicians and care management team members (which may include RN’s, Social Workers, MDs, and Coordinators) to address member needs across the continuum of care as well as provide education and consultation to members, family//caregivers, and other parties involved in the member’s care. The Field Care Manager is expected to make home, nursing home, and other related sites visits around downstate New York.

Duties//Responsibilities:Provides onsite and telephonic care management to support the member’s care needs to promote positive health outcomesApplies care management principles by advocating, informing, and educating beneficiaries on services, self-management techniques, and health benefits related to the continuum of careReviews discharge planning, assessments, medical records, and screening for members recently discharged from inpatient facilities to ensure a safe and successful transitionAssesses need for home care, out of home placement, and//or community-based servicesDevelops care plans that align with the providers’ treatment plans and recommends interventions that align with proposed goalsCompletes assessments to identify barriers and opportunities for interventionGenerates referrals to providers, community-based resources, and appropriate services and other resources to assist in goal achievement and maintenance of successful health outcomesLiaise between service providers such as doctors, social workers, discharge planners, and community-based providers to ensure care is coordinated and care needs are adequately addressedCoordinates and facilitates with the multi-disciplinary health care team as necessary in order to ensure care needs are addressed within members’ care plans and treatment is person-centeredDiscuss opportunities for developing and executing discharge plans with hospital and HF leadershipEvaluates treatment to ensure alignment and execution of the member’s care and physician treatment planAssists in identifying opportunities for alternative care options based on member needs, treatment history and member preferencesContributes to corporate goals through ongoing execution of member care plans and member goal achievement and successful coordination with local supportsDocuments all encounters with providers, members, and vendors in the appropriate system in accordance with internal and established documentation procedures; follows up as needed; and updates care plans based on member needs, as appropriateOccasional overtime as necessaryAdditional duties as assigned

Minimum Qualifications:NYS RN, LMSW, or LCSWAbility to travel around downstate New York which includes; the 5 boroughs, Long Island, and WestchesterMust be fluent in Spanish

Preferred Qualifications:Strong interpersonal and assessment skills, especially the ability to relate well with seniors, their families, and community care providers, along with demonstrated ability to handle rapidly changing crisis situationsExperience in hospital//facility discharge planningKnowledge and experience with the current community health practices for the frail adult population and cognitive impaired seniorsExperience managing member information in a shared network environment using paperless database modules and archival systemsExperience and knowledge of the relevant product lineDemonstrated ability to manage large caseloads and effectively work in a fast-paced environmentProficient with simultaneously navigating the Internet and multi-tasking with multiple electronic documentation systemsExperience using Microsoft Excel with the ability to edit, search, sort//filter and analyze data

Hiring Range*:

Greater New York City Area (NY, NJ, CT residents): $83,100 - $120,360

All Other Locations (within approved locations): $73,400 - $108,160

As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.

In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.

*The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.