Health Home Case Manager

August 29, 2018

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.
  • 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.

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.


Minimum Experience and Skills REQUIRED:

  • Bilingual Spanish/English.
  • 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
  • Willing to consider MSWs who can obtain license within six months of hire.

Job Type: Full-time

How To Apply

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