Care Manager

Job Summary:

The Care Manager plays a vital role in supporting clients with their Health-Related Social Needs (HRSNs). This position is responsible for the full spectrum of care management activities—from screening and eligibility assessment to service navigation, referral coordination, and follow-up. Care Mangers work collaboratively with health care and community-based providers to ensure clients access the services and supports needed to improve overall health and well-being.

Essential Job Duties and Responsibilities: (Additional duties may be assigned)

Screening & Assessment

• Conduct standardized HRSN screenings during intake and outreach efforts.
• Determine eligibility for Enhanced Services and coordinate next steps.
• Identify barriers to care such as housing, food, transportation, utilities, safety, and other social needs.

Care Management & Social Navigation

• Develop and maintain individualized Social Care Plans aligned with each member’s goals, preferences, and limitations.
• Set person-centered goals and update care plans based on member progress.
• Connect members to community-based services and confirm follow-through.

Referral Tracking & Follow-Up

• Facilitate warm handoffs to appropriate providers.
• Track referrals, document outcomes, and verify whether the member’s needs were addressed.
• Reassess clients’ needs and revise plans accordingly.

Collaboration & Engagement

• Work alongside healthcare teams and community agencies to support client care.
• Participate in case reviews, coordination meetings, and community events.
• Build relationships with local service providers and maintain updated resource knowledge.

Documentation

• Use electronic platforms to document services, care plans, and outcomes.
• Collect and report data per program guidelines.
• Ensure all member records are accurate, timely, and compliant with standards.

Supervisory Responsibilities:

This position does not have any supervisory responsibilities.

Education and Experience:

Required:

• Bachelor’s degree in social work, Human Services, Public Health, or related field.
• 2+ years of experience in case management, service coordination, or navigation services.
• Familiarity with Medicaid programs, HRSN screening tools, and local community resources.

Preferred:

• Experience working within Health Homes, Managed Care Organizations (MCOs), or Enhanced Services programs.
• Knowledge of NY State social care systems and benefits access.
• Bilingual or multilingual capabilities.

Special Requirements:

• Hybrid schedule with travel to community settings, homes, or agency offices.
• Must have a valid NY State driver’s license and reliable transportation.
• Occasional evening or weekend hours based on client needs.