• Job Description

  Req#: 563170

  
  

  HHHN Mission

  
  

  To provide the best health care, and access to that care, for everyone in our communities.

  HHHN Vision

  
  

  To pioneer an innovative, sustainable and community-focused health system through comprehensive primary care and diverse partnerships.

  
  

  
  

  Proposed Schedule: 40 hours per week. Monday-Friday, 8am-4:30pm.

  
  

  Position Summary

  
  

  The Pediatric Care Manager is an integral part of the care team, enhancing primary care and providing an array of services to the patients and/or families of the network and support to the primary/specialty care settings. In addition- education, coordination, coaching, transfer of self-management skills, addressing barriers (including socio-economic), and guidance will be provided to the patients and families for the purpose of improving the health of our populations, improving the quality of care provided and decreasing overall costs. Implementation of system wide, integrated care plans required, resulting in improved care management activities occurring in the center, telephonically, and occasionally at the patients’ home, hospital or other community setting.

  Essential Duties and Responsibilities:

  • Prioritize referrals and activities according to intensity, need, and required follow-up for assigned caseload of pediatric patients, deploy other care team staff as appropriate
  • Assist, as an integral part of the care team, in identification of and outreach to medium-high risk patients who may benefit from care management services
  • Effectively engage and assess readiness for change/activation measures/functional ability and health status for the purpose of mutual decision making regarding health care decisions whenever appropriate
  • Provide outreach, information, guidance, and education to the patient and/or family, primary care providers and other members of the care team for appropriate healthcare utilization, condition/critical issue management, effective care transitions, improved self-management skills, assessment and elimination of barriers, promoting wellness and preventative care measures and enhanced patient-provider communication
  • Provides a patient-centered holistic assessment including but not limited to the patient’s condition(s), diagnoses, medications, and support system and facilitate collaboration between all of the patient’s treatment providers to develop an individualized/patient-centered care plan that promotes positive and successful outcomes
  • Maintains accurate and timely documentation within multiple concurrent databases/documentation platforms/Athena care plans
  • Develops and maintains partnerships with any and all healthcare and community resources for the purpose of improved population health and patient support
  • Assist in identifying and addressing local gaps in care and services
  • Identify individuals eligible for New York State Health Home enrollment when appropriate
  • May participate in measuring clinical outcomes, data procurement and analysis activities. May represent the Care Management Department on performance improvement teams
  • Provide other services as directed by HHHN to ensure proper care and treatment to the patient

  Qualifications:

  The requirements listed below are representative of the knowledge, skill and ability to perform the essential functions:

  • Bachelor’s degree in a health or human science field or A.A.S. in Nursing with active license is preferred. Will consider an equivalent combination of experience and education
  • Current BLS certification
  • Must have a minimum of two years’ experience in Care Management or Social Work. A Master’s degree may substitute for one-year experience. New York CANS certification is required or must be obtained within first 3 months of employment
  • Must have a valid driver license and be able to travel throughout the service area
  • Must have strong verbal and written communication skills
  • Proficient computer competency, especially as it applies to the handling of electronic medical records and related databases
  • Must be well organized and have the ability to effectively manage multiple cases and projects

  The pay range for this position is $24.48/hour.

• About the company

  Hudson Headwaters Health Network is a not-for-profit, community-based organization serving nearly 100,000 North Country residents from 21 health centers between South Glens Falls and the Canadian border.

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