About Us
We’re Maimonides Health, Brooklyn’s largest healthcare system, serving over 250,000 patients each year through the system’s 3 hospitals, 1800 physicians and healthcare professionals, more than 80 community-based practices and outpatient centers. At Maimonides Health, our core values H.E.A.R.T drives everything we do. We uphold and maintain Honesty, Empathy, Accountability, Respect, and Teamwork to empower our talented team, engage our respective communities and adhere to Planetree's philosophy of patient-centered care. The system is anchored by Maimonides Medical Center, one of the nation’s largest independent teaching hospitals and home to centers of excellence in numerous specialties; Maimonides Midwood Community Hospital (formerly New York Community Hospital), a 130-bed adult medical-surgical hospital; and Maimonides Children's Hospital, Brooklyn's only children's hospital and only pediatric trauma center. Maimonides' clincal progams rank among the best in the country for patient outcomes, including its Heart and Vascular Institute, Neuroscience Institute, Boneand Joint Center, and Cancer Center. Maimonides is an affiliate of Northwell Health and a major clinical training site for SUNY Downstate College of Medicine.
Overview
The Care Manager has overall day-to-day responsibility for coordinating the activities of the care team for patients with complex medical and/or psychiatric co-morbid conditions and for facilitating patients’ access to the full range of medical and psychosocial services in an efficient and effective manner.
Responsibilities
Collaborates closely with the interdisciplinary care team (PCP, psychiatrist, therapist, residential services, substance abuse programs, ACT Team, etc.) and the Care Navigator to ensure optimal communication and coordination of care.
Reviews patient intake assessments and collaborates with providers, patients, and families to develop and document individualized care plans, self-management goals, and strategies in the EMR.
Identifies and helps resolve barriers to care, outreaches to patients who have not met treatment goals, and adjusts care plans as needed.
Evaluates medication adherence, ensures medication reconciliation is current, and addresses any barriers to compliance.
Actively participates in care transitions by responding to alerts for inpatient and ER admissions, visiting patients during hospital stays, coordinating discharge planning, and following up within 24 hours post-discharge.
Facilitates preventive care by scheduling appointments, arranging screenings per evidence-based guidelines, and ensuring patients and caregivers receive and understand test results.
Provides or arranges patient education, self-management and wellness programs, and assists patients/families with benefits, housing, and entitlement applications while participating in case conferences as needed.
Qualifications
BA/BS degree required.
2-5 years of experience required in providing direct services to individuals with Serious Mental Illness, developmental disabilities or alcoholism or substance abuse, or linking individuals with Serious Mental Illness, developmental disabilities or alcoholism or substance abuse to a broad range of services essential to successful living in a community setting (e.g. medical, psychiatric, social, educational, legal, housing, and financial services).
Excellent computer skills necessary.
Demonstrated ability to use word processing, spreadsheet and/or database programs as required by the position.
Excellent oral and written communication skills.
Excellent interpersonal skills.
Good problem-solving, decision‑making and judgment skills.
Must read, write and speak English to the extent required by position; knowledge of second language preferred.
Pay Range
USD $35.12 - USD $39.55 /Hr.
Equal Employment Opportunity Employer
Maimonides Medical Center (MMC) is an equal opportunity employer.