Complex Case Manager (Social Services) - ACO

About Intention Healthcare, An Essen Health Care Company As the largest privately held multispecialty medical group in the Bronx, we provide high-quality, compassionate, and accessible medical care to some of the most vulnerable and underserved residents of New York State. Guided by a Population Health model of care, Essen has five integrated clinical divisions offering urgent care, primary care, and specialty services, as well as nursing home staffing and care management. Founded in 1999, our over 25-year commitment has fueled an unwavering dedication toward innovating a better healthcare delivery system.

Intention Healthcare is a division of Essen providing physician house calls, and it is the largest provider of house calls in New York. We provide compassionate medical care and care management services to ensure that our over 40,000 disabled and otherwise homebound seniors can live safely, comfortably, and with dignity in their homes.

Position Title Complex Case Manager (Social Services) - ACO

Position Summary The Complex Case Manager (CCM) works in collaboration with the primary care provider and all other members of the care team to support our highest needs, most vulnerable patients, who are frequently in and out of institutional care. Part Patient Advocate, part case worker, part educator, the CCM is responsible for direct and indirect patient care, identifying clinical and health-related social needs and connects patients with relevant community resources.

• Develop rapport with patients and family, conducting frequent check-ins and wining the patient’s trust in order to become their first call with all things related to their health.
• Occasionally visit patients in their homes to conduct safety assessmnts, patient education, and address social needs.
• Perform root-cause analysis of patient’s hospitalizations. Help the clinical team to understand where balls are dropped. What are the social, behavioral, and family dynamics at play that caused warning signs to be missed so that we couldn’t intervene in time, and how might we work with that patient and their support system to do better next time?
• Educate about, refer to, and help patients apply to community resources, city and state programs.
• Assist with and facilitate the transition of care from inpatient settings such as hospital, rehabilitation facilities and skilled nursing facilities to home.
• Address medication adherence and other treatment adherence.
• Communicate changes in patient’s status timely with the care team.
• Work with the Administrative staff to provide feedback that can assist in identifying and improving day-to-day operational processes.

Need to have

• Bachelors in Social Work, or similar
• 2+ experience in health care, and/or health-related social work
• A strong customer-service orientation, and extremely good verbal communication skills. Are you someone who’s going to run through walls to make sure our vulnerable patients get the care they need, despite the many barriers to care they face (or that they create for themselves)?
• The ability to work independently and exercise judgment in interactions with providers, patients, and their families/caregivers
• Ability to function in a fast-paced environment, to be held accountable for high performance standards, and to hold others accountable for high performance
• Good understanding of health care and health insurance concepts Medicare, Medicaid, Long Term Care, home health, behavioral health, Advanced directives and hospice care, etc.
• Personality traits curiosity, empathy, persistence

Nice to have

• Fluency in additional language(s), especially spanish
• Certified Medicaid Assistor, or interest in gaining the certification
• Intermediate excel skills
• Some experience with electronic health records

Essen Health Care is proud to be an equal opportunity employer, and we seek candidates who desire to work in and serve an ethnically diverse population.