Social Work - Home Health Social Worker
FreedomCare
Rochester, NY
5x8 hrs, Days

About our Company

FreedomCare is a healthcare company that has been dedicated to revolutionizing the home care industry since 2016. We support our patients by ensuring they have the power to choose a caregiver who will care for them in the comfort of their own homes. Our mission spans coast to coast, supporting patients across the U.S.

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

Department & Position Overview:

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.

Every Day You Will:

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
Ideal Candidate Will Possess:

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), minimum associate's degree.
Nice-to-Haves:

Bilingual Spanish, strongly preferred
Master's degree is a plus
3+ years of Health Homes experience
3+ years of HARP experience
Why work at FreedomCare?

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 FreedomCare, we celebrate diversity and are committed to creating an inclusive environment for all employees. We are an Equal Opportunity Employer and do not discriminate based upon race, religion, color, national origin, ancestry, age, sex (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity or expression, status as a protected veteran, status as an individual with a disability, citizenship or immigration status, or other applicable legally protected characteristics.