SCN Enhanced Care Manager

Ready to Make a Difference? If you're passionate about helping individuals overcome barriers to care and connecting them with the resources they need to thrive, we encourage you to apply today. Join FLIPA and become part of a mission-driven team dedicated to improving health outcomes and strengthening communities across Upstate New York. Job Title: SCN Enhanced Care Manager Reports to: TBD Location: Hybrid with periodic required in-person meetings. About Forward Leading IPA: Forward Leading IPA (FLIPA) is a nonprofit membership association of safety net providers working in partnership to provide the highest quality integrated healthcare to historically underserved populations in Upstate New York since 2017. FLIPA is renowned for its commitment to integrating primary care, behavioral health, and social care needs. Our growing membership serves individuals across more than 27 counties and includes federally qualified health centers (FQHCs), behavioral health providers, and a rural health network consisting of eight county public health departments. Position Summary: The Enhanced Care Manager serves as a dedicated care management resource supporting high risk/specialty population members who are eligible to receive enhanced services across the Social Care Network (SCN), including maternal-child health (MCH), postpartum individuals, children and youth, members requiring asthma remediation services, and sensitive conditions population including SUD, SMI, and IDD. This position operates within SCN's Internal Hub using a hybrid embedded model that combines direct community-based engagement with centralized care coordination activities. The Enhanced Care Manager is responsible for completing Health Related Social Needs (HRSN) screening and Eligibility Assessment, care planning, referral management, cross-sector collaboration, member engagement, service coordination, and outcome tracking. This role helps SCN fulfill its commitment to improving health outcomes and reducing barriers for vulnerable populations. Key Responsibilities - Manage a dedicated caseload of members within identified high-risk and specialty populations. - Complete screenings and assessments to identify members’ health-related social needs, eligibility, and service needs. - Develop, implement, and update individualized care plans based on each member’s needs, goals, and available resources. - Connect members to appropriate providers, programs, community resources, and social care services. - Monitor member progress, referral outcomes, and service engagement throughout the care management process. - Provide ongoing support, education, and follow-up to help members navigate services and reduce barriers to care. - Facilitate warm handoffs to appropriate services and community-based supports. - Build and maintain trusted relationships with members, families, healthcare providers, and community partners. - Participate in multidisciplinary case reviews, care conferences, and collaborative planning meetings as needed. - Work onsite or in coordination with partner organizations, including OB/GYN practices, WIC offices, Federally Qualified Health Centers, schools, home visiting programs, and community-based organizations. Hub-Based Responsibilities - Coordinate referrals, service follow-up, and communication across internal and external partners. - Conduct care plan reviews and support ongoing care management activities through SCN-approved processes. - Maintain regular communication and collaboration with healthcare providers, community organizations, and internal team members. - Use multiple systems, workflows, and documentation processes to support timely and accurate care coordination. - Document all member interactions, referrals, care management activities, and follow-up actions in SCN-approved systems. Quality and Compliance - Maintain accurate, timely, and complete documentation in accordance with SCN, organizational, and regulatory requirements. - Ensure care manag…