Housing Care Manager RN at MetroPlusHealth

MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlusHealth has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.

MetroPlusHealth is committed to empowering New Yorkers by uniting communities through care. We believe that Health care is a right, not a privilege. If you have compassion and a collaborative spirit, work with us. You can come to work being proud of what you do every day.

Under the direction of the Manager of Housing Taskforce, the Housing Taskforce Care Manager provides critical support to members experiencing homelessness to optimize their health care and delivery of care experience with expected cost savings due to improved quality of care. They also support those formerly homeless members who are transitioning to permanent housing. This is accomplished through holistic, focused engagement and understanding of the member’s physical, behavioral, and social needs; environment; providers; support system; and resources/services available to them. The Housing Taskforce Care Manager is a creative, efficient, and resourceful problem-solver as part of a dynamic team through telephonic outreach, as well as in field work in member’s homes, facilities, provider offices. The Housing Taskforce Care Manager serves as a member’s advocate and accompanies the member throughout their care journey, assisting with medical and behavioral health stabilization, so that members can maintain or improve their day-to-day functioning.

This is a hands-on, intensive position that is a hybrid remote/office/field position, that will require some field-based work, and travel within the MetroPlusHealth service area. The Housing Taskforce Care Manager will sometimes be needed to physically meet the members where they are to gain a deeper understanding of their situation and needs.

• Assess and address member’s problems and needs: clinical, psychosocial, financial, environmental
• Provide services to members of varying age, clinical scenario, culture, financial means, social support, and motivation
• Engage members in a collaborative relationship, empowering them to manage their physical, psychosocial, and environmental health to improve and maintain lifelong well being
• Support members through transitional period from shelter to permanent housing as well as once they are housed to settle into their new living situation 
• Assess and address risks and gaps in care
• Maximize member’s access to available resources
• Develop a member-centered plan of care with input from member, caregivers, and health care providers, integrating concepts of cultural sensitivity and privacy practices
• Communicate plan of care to Primary Care Physician initially and provide updates, as needed
• Ensure member’s understanding as it relates to language barriers, stress reaction or cognitive limitations/barriers using verbal and nonverbal techniques
• Train member on relevant chronic diseases, preventive care, medication management (medication reconciliation and adherence), home safety, etc.
• Provide complex care management, including but not limited to ensuring access to care, reducing unnecessary hospitalizations, and appropriately referring to community supports
• Advocate for members by assisting them to address challenges and make informed choices regarding clinical status and treatment options
• Develop collaborative relationships with clinical providers and facility staff
• Employ critical-thinking and judgment when dealing with unplanned issues
• Use data as a tool in tracking and trending outcomes and clinical information
• Maintain accurate, comprehensive, and current clinical and non-clinical documents
• Comply with all initial, annual, and other mandatory trainings, organizational and departmental policies, and procedures, and actively participate in evaluation process
• Maintain professional competencies as a Housing Taskforce Care Manager
• Conduct other duties as assigned by Manager of Housing Taskforce

• Master’s Degree in Social Work required
• 3 years of prior experience in care management in a health care and/or managed care setting, or other relevant experience working in the field of Social Work or Case Management required
• Proficiency with computers, navigating in multiple systems and web-based applications, including Microsoft Word, Excel, Teams, PowerPoint, and Outlook, as well as various web-based applications, and portals.
• Ability to proficiently read and interpret medical records, claims data, pharmacy and lab reports, and prescriptions required
• Ability to work closely with members and caregivers.
• Significant experience working with clients around the issues of homelessness, addictions, mental health, entitlements, and housing 
• Have a working knowledge of members’ rights and responsibilities as tenants. 
• Have experience working on-site in a behavioral health practice setting.
• Bilingual (English/Spanish) preferred

Licensure and/or Certification Required: 

• Valid unrestricted NYS license as LMSW or LCSW 

Professional Competencies: 

• Confident, autonomous, solution driven, detail oriented, high standards of excellence, nonjudgmental, diplomatic, resourceful, intuitive, dedicated, resilient and proactive
• Strong verbal and written communication skills including motivational coaching, influencing and negotiation abilities
• Time management and organizational skills
• Strong problem-solving skills
• Ability to prioritize and manage changing priorities under pressure
• Confident, autonomous, solution driven, detail oriented, high standards of excellence, nonjudgmental, diplomatic, resourceful, intuitive, dedicated, resilient and proactive 
• Ability to travel within the MetroPlusHealth service area including making home visits to members, facility visits to clinical providers, and visits to community, faith, and other social service-based agencies.