About HeartShare 

For over 100 years, HeartShare has dedicated itself to improving the lives of people needing special services and support. The HeartShare team, now 2,100 employees and growing, helps individuals develop to their fullest potential and lead meaningful and enriched lives.    

 

The Care manager has overall day to day responsibility for coordinating the activities of the care team for clients with complex medical and/ or psychiatric co-morbid conditions and for facilitating clients’ access to the full range of medical and psychosocial services in an efficient and effective manner.

Actively participates in multidisciplinary case conferences and projects, collaborating with community-based organizations to meet clients’ needs. Collaborates closely with the interdisciplinary care team, including PCP, psychiatrist, therapist, residential services, and substance abuse programs. Provides input for individualized care plans to providers, clients, and families. Identifies and resolves barriers to care with clients and engages those who have not met treatment goals. Monitors medication adherence, addresses barriers, and ensures current medication reconciliation. Responds to emergency room alerts, visits clients during admission, and participates in discharge planning and care transitions within 24 hours of hospital discharge. Ensures clients keep scheduled appointments and arranges preventive screenings based on evidence-based guidelines. Coordinates care between the client and extended care team to ensure the integrated care plan is executed. Regularly reviews client information to identify outreach needs, engages clients, and addresses quality of care issues. Provides or arranges self-management, wellness education, and peer support in the client's preferred language. Assists with benefits, entitlements, and housing applications, following up to ensure approvals. Complies with all government and funder regulations. Performs additional duties and initiatives as assigned by the Program Director.