Chronic Care Manager

1 month ago

Brooklyn, New York, United States Vitability Health Full time
Job Title: Chronic Care Manager

Vitability Health is leading the change in how patients receive quality care.

Essential Duties and Responsibilities:
  • Manage a caseload of assigned patients with chronic conditions, including those with mental health issues.
  • Collaborate with physicians, providers, and practice staff to identify patients for care management.
  • Develop relationships with patients as an integral member of the care team.
  • Provide follow-up management to ensure patients comply with their individual care plans.
  • Maintain availability for telephone advice and handle urgent and emergency calls during working hours.
  • Anticipate patient needs, ensuring necessary documentation and pre-visit planning is completed or requested before patient visits.
  • Promote patient self-management and empower patients/families to achieve maximum levels of wellness and independence.
  • Determine and coordinate appropriate referrals as needed.
  • Work with patients and their care team to coordinate change readiness, needs assessment, and develop individualized treatment care plans.
  • Collaborate with patients, physicians, and other care team members to assess patient progress toward individual health care goals.
  • Maintain accessible, consistent documentation of patient self-management measures and reporting progress toward goals.
  • Assist patients in setting SMART goals for self-management, teaching them how to perform self-management tasks, and report abnormal findings to their physician team.
  • Assess barriers when patients have not met treatment goals, are not following treatment plans, or have not kept important appointments.
  • Participate in regular team meetings and peer review activities.
  • Promote collaborative teamwork and work with peers in a team situation.
  • Collaborate with payer Case Managers for additional services when appropriate.
  • Maintain a list of medical supply and community resources available to patients and maintain collegial relationships with frequently used entities.
  • Make recommendations for policies/procedures to ensure preventive services are offered in a timely manner to all who qualify.
  • Provide follow-up in transitions of care from various settings (hospital or skilled nursing facility discharges and emergency room visits).
  • Coordinate disease registry activities.
  • May conduct home visits with a physician to assess safety, medication compliance, and home environment.
  • Participate in departmental and organizational committees as applicable.
Qualification Requirements:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this job.

The Case Manager must have knowledge of the Patient-Centered Medical Home model/mission as well as knowledge of insurance industry practices and requirements.

He/she must have an understanding of chronic disease and preventive care measures.

Must have a bachelor's degree in healthcare administration, health informatics, or a related field and hold licensure as a Licensed Practical Nurse, or an incumbent holding licensure as a Licensed Practical Nurse and having significant experience in chronic care may be considered.

Licensure as a Registered Nurse is preferred. Experience working with patients with mental health issues is preferred.

  • Chronic Care Coordinator

    1 month ago

    Brooklyn, New York, United States Vitability Health Full time

    Job Title: Chronic Care ManagerVitability Health is revolutionizing the way patients receive quality care.Key Responsibilities:Manage a caseload of patients with chronic conditions, including those with mental health issues.Collaborate with healthcare providers to identify patients who would benefit from care management.Develop relationships with patients...

  • Chronic Care Coordinator

    3 weeks ago

    Brooklyn, New York, United States Vitability Health Full time

    Job Title: Chronic Care ManagerVitability Health is revolutionizing the way patients receive quality care.Key Responsibilities:Manage a caseload of patients with chronic conditions, including those with mental health issues.Collaborate with physicians, providers, and staff to identify patients for care management.Develop relationships with patients as a key...

  • Chronic Care Coordinator

    1 month ago

    Brooklyn, New York, United States Vitability Health Full time

    Job SummaryVitability Health is revolutionizing the way patients receive quality care. We are seeking a skilled Chronic Care Manager to join our team.Key ResponsibilitiesManage a caseload of patients with chronic conditions, including those with mental health issues.Collaborate with physicians, providers, and practice staff to identify patients for care...

  • Chronic Care Coordinator

    2 months ago

    Brooklyn, New York, United States Vitability Health Full time

    Job SummaryVitability Health is revolutionizing the way patients receive quality care. We are seeking a skilled Chronic Care Manager to join our team.Key ResponsibilitiesManage a caseload of patients with chronic conditions, including those with mental health issues.Collaborate with physicians, providers, and practice staff to identify patients for care...

  • Care Manager

    3 weeks ago

    Brooklyn, New York, United States MetroPlus Health Plan Full time

    About the RoleThe Care Manager will play a critical role in optimizing members' healthcare and delivery of care experience with expected cost savings due to improved quality of care.Key ResponsibilitiesAssess and evaluate members' needs, be a creative, efficient, and resourceful problem solver.Develop, implement, and evaluate plans of care with...

  • Care Manager

    3 weeks ago

    Brooklyn, New York, United States MetroPlus Health Plan Full time

    Job Title: Care ManagerAt MetroPlus Health Plan, we are committed to empowering New Yorkers by uniting communities through care. We believe that healthcare is a right, not a privilege. If you have compassion and a collaborative spirit, we invite you to join our team.Job Summary:The primary goal of the Care Manager is to optimize members' healthcare and...

  • Care Manager Position

    2 weeks ago

    Brooklyn, New York, United States i4 Search Group Full time

    The Behavioral Health Care Manager will be responsible for reviewing patient charts and communicating with the Clinical department and providers about any irregularities as part of chronic care management.Key Responsibilities:Initiates behavioral health care planning concerning behavioral or psychiatric health problemsRevises / modifies care plans for...

  • Nurse Practitioner

    3 weeks ago

    Brooklyn, New York, United States Chai Urgent Care Full time

    Job SummaryWe are seeking a skilled Nurse Practitioner to join our team at Chai Urgent Care. As a primary care specialist, you will be responsible for delivering high-quality medical care to a diverse range of patients. Your expertise in family health will enable you to provide comprehensive care, from routine check-ups to managing chronic conditions.Key...

  • Behavioral Health Care Manager

    4 weeks ago

    Brooklyn, New York, United States i4 Search Group Full time

    Job Description:The Behavioral Health Care Manager will be responsible for reviewing patient charts and communicating with the Clinical department and providers about any irregularities as part of chronic care management. This role requires a strong understanding of behavioral health principles and practices, as well as excellent communication and...

  • Nurse Care Specialist

    3 weeks ago

    Brooklyn, New York, United States HOPE HOME CARE Full time

    Hope Home Care, Inc. is a home care agency with a rich history of connecting professionals with opportunities to make a meaningful impact in the lives of vulnerable individuals in our community.Job SummaryWe are seeking a skilled and compassionate Nurse to provide one-on-one care to patients in their homes. As a member of our team, you will have the...

  • Behavioral Health Care Manager

    2 weeks ago

    Brooklyn, New York, United States i4 Search Group Full time

    Job Description:The Behavioral Health Care Manager will be responsible for reviewing patient charts and communicating with the Clinical department and providers about any irregularities as part of chronic care management. This role requires a strong understanding of behavioral health principles and the ability to work collaboratively with the care team to...

  • Care Specialist

    3 weeks ago

    Brooklyn, New York, United States Upward Health Full time

    About Upward HealthUpward Health is a leading provider of in-home, multidisciplinary medical care, delivering 24/7 whole-person care to patients in need. Our team of dedicated professionals is committed to improving the lives of our patients through exceptional care and support.Job SummaryWe are seeking a highly motivated and compassionate Care Specialist to...

  • Advanced Care Provider

    3 weeks ago

    Brooklyn, New York, United States Ennoble Care Full time

    About UsEnnoble Care is a pioneering mobile healthcare service provider dedicated to delivering exceptional care to patients in their homes. Our team of skilled clinicians offers a continuum of care for individuals with chronic conditions and limited mobility, ensuring they receive the highest quality of care in a familiar environment.Our MissionWe are...

  • Nurse Care Manager

    2 weeks ago

    Brooklyn, New York, United States DaVita Full time

    About the RoleWe are seeking a skilled and compassionate Registered Nurse to join our team as a Peritoneal Dialysis RN. As a key member of our healthcare team, you will be responsible for providing high-quality patient care and education to patients with end-stage renal disease.Key ResponsibilitiesProvide comprehensive patient care in an independent setting,...

  • Primary Care Physician

    1 month ago

    Brooklyn, New York, United States PAGNY Full time

    Join Our Team as a Primary Care PhysicianWe are seeking a highly skilled and compassionate Primary Care Physician to join our team at NYC Health + Hospitals/South Brooklyn Health. As a member of our team, you will have the opportunity to make a meaningful impact on the lives of our patients and contribute to the delivery of high-quality healthcare...

  • Senior Community Care Nurse Practitioner

    3 weeks ago

    Brooklyn, New York, United States Optum Full time

    Senior Community Care Nurse PractitionerOptum Home and Community Care is seeking a Senior Community Care Nurse Practitioner to join our team. As a key member of our interdisciplinary care team, you will provide high-quality, patient-centered care to our most vulnerable populations. With a focus on geriatrics and chronic illness, you will work closely with...

  • Care Specialist

    3 weeks ago

    Brooklyn, New York, United States Upward Health Full time

    Job Title: Care SpecialistWe are seeking a dedicated and compassionate Care Specialist to join our team at Upward Health. As a Care Specialist, you will play a vital role in delivering high-quality care to our patients in their homes and communities.Key Responsibilities:Conduct direct outreach to patients via phone, in-person, and other strategies to enroll...

  • Pain Management Specialist

    3 weeks ago

    Brooklyn, New York, United States Atlas Search Full time

    Pain Management Physician OpportunityAtlas Search is seeking a highly skilled Pain Management Physician to join our team. As a key member of our healthcare team, you will provide expert medical care for patients suffering from chronic pain conditions.Key Responsibilities:Evaluate and diagnose patients with chronic pain conditions using a comprehensive...

  • Wound Care Specialist

    2 weeks ago

    Brooklyn, New York, United States HealWell, LLC Full time

    We are seeking a dedicated Wound Care Specialist to join our healthcare team. The ideal candidate will provide specialized care for patients with chronic or acute wounds, promoting healing and preventing complications.Key Responsibilities:Regularly assesses and evaluates the condition of acute and chronic wounds.Performs wound consultation, wound care,...

  • Adult Day Health Care Case Manager

    3 weeks ago

    Brooklyn, New York, United States Housing Works Full time

    About the RoleHousing Works is seeking a skilled Licensed Master Social Worker/Case Manager to join our Adult Day Health Care (ADHC) Program in Brooklyn. As a key member of our interdisciplinary team, you will provide mental health/substance use/supportive counseling, crisis interventions, and case management services to clients living with chronic...