Health Home Care Manager; Rochester, NY​/Field

Health Home Care Manager (Rochester, NY / Field-based)

Join to apply for the Health Home Care Manager (Rochester, NY / Field-based) role at Freedom Care

Started in 2016, Freedom Care is a Healthcare company that is innovating and revolutionizing the way home care is delivered. We bring dignity and support to patients needing care in their homes and to the caregivers who care for them. We’re the largest consumer‑directed home care agency in NY State and are continually expanding our areas of focus including operations in other states and tech‑based innovations.

We pride ourselves on our values which drive the level of care that we deliver to our patients:

• Here For You (An attitude of service, empathy, and availability)
• Own It (Drive and ownership)
• Do the Right Thing (High integrity)
• Be Positive (Great attitude and a can‑do positive approach to challenges)

Join our team and make a positive impact on the lives of others! We are looking for a Health Home Care Manager for our Care Management team in upstate NY
.

This position requires travel to patients’ homes in Rochester, NY and surrounding areas within Monroe County.

The Health Home Care Manager will work to outreach and engage potentially eligible patients and obtain appropriate consents to enroll the patient in the Health Home Care Management Program. Once the patient is enrolled, the Health Home Care Manager will work collaboratively with the patient’s care team to complete a comprehensive assessment and patient‑centered care plan, and to coordinate care based on the care plan.

• Screen for Health Home functional scale eligibility, conduct initial Health Homes assessments and reassessments of patient needs, including medical, mental health, substance use, financial, housing, and additional support needs.
• Collaborate with the medical providers and patients to develop, implement, and coordinate Health Homes compliant care plans for patients with chronic diseases, such as diabetes, asthma, congestive heart failure, hypertension, mental health conditions, substance use, and more and document care plan outcomes.
• Provide direct service to a caseload of chronically ill patients and help them achieve their care plan goals by facilitating referrals, addressing access issues, connecting them to local resources, and developing relationships with healthcare providers.
• Coordinate patient services and care with pharmacies, insurance companies, hospital discharge planning, family caregivers, and other providers.
• Provide crisis intervention when needed.
• Conduct home visits and maintain patient contact and documentation of all services in accordance with Health Homes standards.
• Maintain patient confidentiality at all times.

• Ability to travel in the field to accompany patients to appointments and meet patients in person when needed.
• 1+ year of health homes, HARP or case management experience (required).
• Strong working knowledge of local community resources.
• Demonstrated ability to work with data reporting, documentation, and outcomes.
• Strong communication and assessment skills; the ability to relate to patients, their families, and community care providers, along with ability to handle rapidly changing crisis situations.
• Ability to manage high volume caseloads.
• Able to express empathy and compassion for the underserved.
• Experience navigating several data management systems, such as Salesforce.
• Bachelor’s degree (preferred).

• Bilingual Spanish, strongly preferred.
• Master’s degree is a plus.
• 3+ years of Health Homes experience.
• 3+ years of HARP experience.

We are here for you and committed to providing a best‑in‑class employee experience. We offer competitive compensation, medical benefits, retirement plans, wellness programs, fun company events and ongoing learning opportunities to grow your career.

This is a place where your voice matters, where we build great relationships, and your work has meaning and a tangible positive impact on others.

At Freedom Care, we celebrate diversity and are committed to creating an inclusive environment for all employees. We are an Equal…