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The role of Health Home Accountable Care Manager, primary function is to provide professional social work & care management services to Medicaid members related to a variety of issues such as medical, psychiatric, and substance abuse conditions, hospitalization, finances, and community services.  ACMs guide client’s through the health care system by assisting with access issues, developing relationships with service providers, and tracking interventions and outcomes. ACM’s provide direct services to patients including the completion of needs assessments, development of patient focused care plans, periodic reassessments and overall comprehensive service coordination

Essential Functions:

·         Provides direct service to clients using motivational interviewing and other supportive counseling

·         Screens for functional scale eligibility, conducts initial assessments, and periodic reassessments of patients’ needs including medical, mental health, substance use, financial, housing and support needs.

·         Provides crisis intervention and health education services as needed.

·         Develops patient focused care plans with documented input and approval from other providers and the patient in compliance with Health Home standards. .

·         Work with the medical staff to develop, implement, and coordinate the care plan for patients with chronic diseases, such as diabetes, asthma, congestive heart failure, hypertension, mental health condition, and substance abuse etc, based on the Health Home chronic disease care coordination model standards.

·         Conducts home/field visits and maintains patient contact in accordance with program standards.

·         Visits health home members in ER, hospital and other settings to alternative level of care, if needed.

·         Coordinates patient services with internal and external service providers through regular case conferencing.

·         Ensures appropriate record documentation from all members of the case management team.

·         Documents the outcomes of care plans in the case record.

·         Assist in coordinating care with pharmacies, insurance companies, hospital discharge planning and other providers in the Network.

·         Work schedule is Monday- Friday 8:30am-5:00pm

Qualifications & Competencies:

·         Master’s degree in a social work

·         Position requires one of the following LMSW/LCSW

·         The position requires excellent clinical skills

·         Must have excellent written and verbal communication skills

·         Proficient in Microsoft Word

·         Bilingual Spanish preferred

Competitive Salary & 1199 Union Benefits including Medical, Dental, Vision, 403B Plan, Tuition Assistance, Accrued Vacation, Personal and Sick Benefits.


Department: UBA Bargaining Unit: 1199 Campus: MOSES Employment Status: Regular Full-Time Address: 2005 Jerome Avenue, Bronx
Shift: Day Scheduled Hours: 8:30 AM-5 PM Req ID: 103308 


Montefiore is an equal employment opportunity employer. Montefiore will recruit, hire, train, transfer, promote, layoff and discharge associates in all job classifications without regard to their race, color, religion, creed, national origin, alienage or citizenship status, age, gender, actual or presumed disability, history of disability, sexual orientation, gender identity, gender expression, genetic predisposition or carrier status, pregnancy, military status, marital status, or partnership status, or any other characteristic protected by law. 



To heal, to teach, to discover and to advance the health of the communities we serve.

To be a premier academic medical center that transforms health and enriches lives.

Define our philosophy of care, they shape our actions and motivate and inspire us to pursue excellence and achieve the goals we have set forth for the future. Our values include:

  • Humanity
  • Innovation
  • Teamwork
  • Diversity
  • Equity