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HeartShare Bilingual (Russian/English) Care Manager in Brooklyn, New York

Health Home is a Case Management Program offering care coordination and resources for adults with two or more chronic conditions or 1 SMI condition throughout New York City. The goal of the Health Home program is to make sure its members get the care and services needed. This may mean fewer trips to the emergency room or, less time spent in the hospital. It could mean getting regular care and services from doctors and providers. Or, finding a safe place to live, and a way to get to medical appointments. QUALIFICATIONS: * BA/BS Degree Required * Bilingual Speaking- Russian/English * 1-2 years of experience in healthcare, social work or case management. * Strong written and verbal skills * Excellent computer skills are necessary, demonstrated ability to use word-processing, or data base programs. * Knowledge of community resources, and entitlements. * Good organizational and interpersonal skills. * NYS Driver's license with vehicle preferred. This position requires the employee to be on the field about 75% of the time. RESPONSIBILITIES * Participates in conferences, workshops, and other professional development activities to maintain licensure and/or remain professionally current with advances in field of expertise. * Continually reviews the service delivery process. * Participates in multi-disciplinary case conferences and projects, demonstrating team spirit and ability to work with other community based organizations to meet clients' needs. * Works closely with the interdisciplinary care team including PCP, psychiatrist, therapist, residential services, substance abuse treatment program, ACT Team, etc. * Works closely with the Care Navigator to ensure the flow of information across and between the care team is optimized. * Provides input to providers/client/family for written individualized care plans * Reviews client intake assessment and uses results to coordinate the completion of the care plan, self-management goals and strategies; documents them in EMR * In conjunction with the client, identifies potential barriers to care and resolutions to those barriers; outreaches to clients who have not met treatment goals to resolve barriers/adjust goals when possible * Evaluate medication compliance and assess potential barriers to adherence; ensure medication reconciliation is current * Receives alerts in client and ER admissions of targeted clients , visits clients during client stays and participates actively in discharge planning and care transition activities; and contacts clients on the day of discharge from client services and ER or within 24 hours * Outreaches to clients to facilitate keeping scheduled appointments; arranges for metabolic and periodic preventive screening, per evidence based guideline standards * Ensures that clients and care givers are aware of test results by facilitating a discussion between the client and physician as necessary * Coordinates services between client and extended care team providers to ensure that integrated care plan is fully implemented * Regularly reviews client information from care team members to identify clients requiring outreach and engagement, and identifies quality of care issues and refers appropriately. * Provides or arranges for provision of self-management/ wellness education, peer and other support groups in the language that the client/family prefers. * Organizes and participates in case conferences, workshops, and other professional development activities to maintain licensure and/or remain professionally current with advances in field of expertise. * Reviews benefits, entitlements, housing with the client/family and assist in the application process. Follows up as necessary to ensure services are approved. * Abide by all HeartShare policies and procedures. * Represent HeartShare, both within and outside the organization, in a manner that promotes the Mission, Vision, Values and Goals. * Remain sensitive and responsive to the cultural and religious differences present in the clinic's client population and staff. * Responsible for providing progressing diligent search efforts that includes mailing letters, making phone calls, and community/home visits Responsible for managing an assignment list potential Health Home members over a 30-60 day period * Provide comprehensive education to potential Health Home clients that highlights the benefits and promotes participation in care coordination services * Conducting home visits, field visits, phone and mail outreach as dictated by City and State Policy. * Conduct home visits, phone and mail outreach to individuals referred for enrollment. * This position requires the candidate to be on the field about 75% of the time and take mass transit to travel from one site location to another. * Undertake any additional tasks and initiatives as assigned by the Program Supervisor or Senior Director. Salary: $47,000.00 /year Benefits: * Rewarding Work in a team environment; * Paid vacation, sick, personal days and holidays; * 403(B) retirement plan with employer contribution; * Health, dental, vision and life insurance; * Employee Assistance Program (EAP); * Flexible spending account (Dependent Care, Medical, Parking, and Transit); * Employee Appreciation Programs and Events; * Tuition Assistance Program; * Professional Development opportunities; * Verizon Wireless Discount; * BJs Membership discount; * Discounts on Broadway tickets, movie tickets, theme parks, sporting events, gift certificates & more. * Bachelor's degree in human services or related social service field; required. * Minimum 2 years working with the homeless population as a case manager or in a similar capacity. * Familiarity with case management entitlement systems, and a knowledge of issues that impact families a plus. * Knowledge of DHS regulations and CARES a plus * Bilingual (Spanish) preferred Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled