The Community Health Care Manager is responsible for engaging with PPS community health partners and supporting strategy implementation. This includes coordinating the care of health plan members with chronic medical and behavioral health conditions across the continuum of care; ensuring and facilitating the achievement of quality, clinical and cost outcomes. The Community Health Care Manager may work from a variety of locations. The discrete activities include member outreach, care planning, motivational interviewing and acting as a key clinical liaison between the provider, member and SI PPS. The Community Health Care Manager will also be responsible for coordinating community health outreach events and activities across participating SI PPS partners. Activities include ongoing follow-up, performance monitoring and community engagement activities. In-person participation is expected for this role.
- Utilizing care coordination skills, work directly with members and providers to assess, triage and develop care management plans to allow members to receive appropriate care in the least restrictive level of care and avoid hospitalization.
- Build and foster relationships with community-based organizations, health plans, coalitions, health care systems in the designated geographic area to understand the needs of the community, and the organizations providing access.
- Collaborate with members/families, providers, medical/behavioral health staff and/or others in order to coordinate and support care plans that include mutual and realistic goals, interventions, and expected outcomes and that support quality and medical/behavioral health management goals and objectives.
- Engage, communicate with and coach patients face to face and telephonically. Educate members (family/caregivers) regarding their disease process and self-management strategies.
- Identify and facilitate access to social service agencies, community organizations, patient support groups, and other adjunct services to minimize and prevent inappropriate hospital stays and maintain maximum achievable health status.
- Identify members who maybe high risk for Mental Health/Substance Abuse problems treatment and are not currently involved in the treatment system and help the member avoid admissions into hospital levels of care.
- Lead and monitor the implementation of community health programs across PPS network partners.
- Organize and/or facilitate consumer listening sessions to understand needs directly from residents of the community.
- Communicate critical community needs and provide updates to the Population Health team regarding successes, challenges and outcomes
- Empower community-based partners in order to strengthen their voice and promote the importance of their services to the medical care delivery organizations
- Maintain awareness of other regional activities and positioning to develop effective approaches to collaboration with other organizations within and across regions
- Performs other duties as assigned.
- Bachelor’s Degree in related health, social services field highly preferred.
- Master’s Degree or clinical equivalent preferred.
- 3+ years of case management experience required.
- 3+ years of experience engaging and organizing community-based organizations or building community-based service networks required; program management experience preferred
- Extensive knowledge and understanding of social determinants of health, community-based organizations (CBOs), health equity, health care systems, and value-based purchasing (VBP) a strong plus
- Demonstrated experience preparing and presenting proposals, reports, updates, data, summaries, etc.
- Able to travel locally, approximately 50% as needed
- Comfortable working in a fast-paced, dynamic environment focusing on key goals
- Flexible work style and ability to adapt to changing responsibilities and requirements
- Ability to perform and thrive in a team-based environment
- Demonstrated ability to build constructive working relationships with others inside and outside the organization through cooperation and mutual respect
- Excellent oral and written communication skills
- Takes personal responsibility for the quality and timeliness of work and achieves results with little oversight. Conducts oneself with confidence, flexibility, and personal credibility.
- Demonstrated knowledge of continuous quality improvement techniques
- Continue to enhance professional education and maintain all requirements for licensure and certifications.
- Accomplishes work in accordance with all policies in the Employee Handbook, including the Employee Code of Conduct, HIPAA and Confidentiality.
- The employee agrees to comply with Corporate Compliance Policy and all laws, rules, regulations and standards of conduct relating to the Corporate Compliance Policy.
Status: Full Time, Exempt
Staten Island Performing Provider System offers a competitive salary and full benefits.
Please send a resume to Ashley Restaino at firstname.lastname@example.org.