The William F. Ryan Community Health Network is a group of not-for-profit, federally qualified health centers that deliver high quality, affordable and comprehensive medical care to diverse and underserved communities. We are currently seeking a Health Home Case Manager for our William F. Ryan Community Health Center located on the Upper West Side of Manhattan.

Position Overview:

The Health Home Case Manager provides care coordination, health education, and health promotion services to address barriers to care and to ensure that patients with targeted chronic medical conditions, including pediatric asthma, coronary heart disease/hypertension, adult diabetes, HIV, and mental illness, have access to and obtain needed medical, behavioral health and social services to optimize their health status. This worker will assume responsibility for the HARP assessments. This work is carried out in support of the mission and goals of the Ryan Network.

Essential Functions:

Care Coordination

  • Assess patients for patient care coordination and care management services including health home enrollment through intake, meetings with the patient, the patient’s family and/or care givers, and review of relevant documentation to develop a care plan; obtain input on the patient’s ability to self-care, identify psychosocial stressors and barriers to care including health insurance, housing, financial assistance, learning difficulties and other disabilities.
  • Develop a comprehensive care plan to address barriers and expected health outcomes and self-management goals incorporating, as clinically appropriate, the role of medical practitioners, behavior health providers and other community providers, including housing and social service agencies, to address the patient’s needs and assure continuity of care.
  • Function as a team member together with other health care practitioners by collaborating actively with other disciplines and by maintaining communication with other practitioners as appropriate regarding the healthcare needs of the patients both within the Mental Health Department, and between Departments.
  • Collaborate and consult with the patient’s care team, including both Ryan and non-Ryan providers, in identifying service gaps as a part of care planning, case disposition, and case closure.
  • Schedule patient appointments with Ryan providers and, as necessary, provide referrals and appointment follow-up with non-Ryan service and medical providers.
  • Inform and assist patients with enrolling in relevant benefits and entitlement programs and health insurance programs through the New York State Health Marketplace.

Outreach and enrollment

  • Conduct intensive outreach to patients that have disengaged or are at risk of disengaging from care, and individuals whose psychosocial stressors are limiting their success in achieving healthy outcomes and who can benefit from patient navigation, including enrollment and participation in New York State Health Home.
  • Provide home, hospital, or community site visits and escort patients to medical and non-medical appointments as indicated in the patient’s care plan, and as approved by staff Monitor and/or Supervisor.
  • Collaborate with Health Home, Case Management and Behavioral Health administration, administrators and team members, along with local and Network wide administrators, to develop and implement strategies to reach target populations.
  • Develop linkages between community agencies and resources to ensure continuity of care.
  • Experience in consultation, assessment, and up to date knowledge of
  • Experience with one or more of the following: severe mental illness, substance abuse,
    children, individuals living with HIV+ and other chronic conditions.
  • Knowledge and treatment of addictions.
  • Experience in behavioral health outpatient settings.

Documentation and Quality Assurance

  • Ensure completion of mandated assessments within specified time periods according to regulatory bodies, including the New York State Department of Health.
  • Maintain patient records in accordance with agency protocols and standards using Ryan’s electronic medical record system, as well as care management systems used between Ryan and the State of New York, to ensure that patient needs are effectively communicated across delivery systems.
  • Participate in Quality improvements/Performance Improvement (QI/PI) teams, as assigned for the purpose of identifying, planning, implementing and evaluating (QI/PI) initiatives.
  • Submit weekly, monthly and quarterly data reports as requested.


  • Attend all meetings and/or training sessions as required.
  • Immediately report any problems or unusual occurrences to supervisor.
  • Perform other duties and projects as assigned.
  • Submit weekly, monthly and quarterly data reports as requested.

Minimum Experience and Skills Required

  • Minimum two years of relevant experience working in a medical setting with a population with chronic conditions.
  • Strong working knowledge of MS Outlook, Word, and Excel.
  • Database management experience.

Education, Licenses, and/or Certifications Required:

  • Master’s degree in Social Work.
  • LMSW

Preferred Qualifications:

  • Bilingual English/Spanish or English/French

Equal Opportunity Employer
Ryan Network is an Equal Opportunity / Affirmative Action Employer and does not discriminate because of age, color, disability, ethnicity, marital or family status, national origin, race, religion, sex, sexual orientation, gender identity, military veteran status, or any other characteristic protected by law. We are committed to attracting, retaining and maximizing the performance of a diverse and inclusive workforce.

Please forward resume by email to, and reference the job title in the subject line.