Health Home Care Coord
About The Position
Under general direction and with significant independence, the Children’s Health Home (CHH) Care Coordinator provides comprehensive care management for patients referred by CHHUNY. In collaboration with each enrolled child’s primary care provider and other involved providers, the coordinator engages and enrolls participants, assesses their needs, and develops and implements care plans addressing medical, behavioral, psychosocial, and social determinants of health needs and goals. Consistent with New York State regulations and CHH policies, the coordinator analyzes patient-level data to track adherence to treatment protocols and provides non-clinical interventions to help participants overcome barriers to access and care. The role involves regular communication and collaboration with patients, families, pediatricians, other medical and behavioral health providers, community agencies, and office staff to adapt support and improve health outcomes. The position is full-time, 40 hours per week, on the University of Rochester day shift. It is based at 905 Elmgrove Road, Rochester, New York. The listed compensation range is $23.51–$31.74; individual pay is determined using factors including market data, education, experience, qualifications, expertise, and internal equity.
Requirements
- Bachelor’s degree in an appropriate human services field and one year of experience providing direct services to people with serious mental illness, intellectual or developmental disabilities, or alcoholism or substance abuse, or experience effectively linking people with services addressing social determinants of health; an equivalent combination of education and experience is accepted.
- Valid in-state driver’s license with a satisfactory driving record upon hire.
- Must meet pre-employment requirements.
Nice To Haves
- Experience providing outreach and care management services for a diverse population of children and their families in the Rochester community.
- Experience with home visiting and working with health care professionals in a team-based approach to care.
- Strong interpersonal skills for engaging patients in case management services.
- Strong organizational skills; ability to navigate and document in electronic systems, use tracking platforms, and communicate concisely orally and in writing.
Responsibilities
- Intake referred patients by completing Children’s Health Home consent and engaging the patient or family in completing the CANS-NY assessment.
- Develop a preliminary care plan with the family using assessment information, addressing the child’s physical and mental health, growth and development, education, parenting, safety, home stability, trauma, and social relationships.
- Download consent forms, CANS assessments, and plans of care into the Netsmart care management system.
- Provide face-to-face services, including home visits, and telephone contact with participants and guardians to advance care plans and support adherence to medical and behavioral health care while helping avoid preventable emergency department visits and hospitalizations.
- Provide information and referrals to community resources; monitor attendance at health and behavioral health appointments; and reassess care plans as needed.
- Identify situations requiring incident and compliance reporting and immediately inform the Senior Social Worker; escalate care management when needed.
- Transport a patient with the patient’s guardian when needed.
- Complete required documentation within established time frames and according to CHHUNY, hospital, and Social Work Division standards.
- Complete monthly billing sheets accurately to reflect billable services.
- Meet with the Senior Social Worker, Quality Manager, and other CMA staff to achieve quality standards.
- Collaborate with community providers and resources to obtain services and supports, using community and family resources to create a sustainable support system.
- Participate in team and patient meetings as needed or requested by the patient, family, or team.
- Coordinate care with ambulatory and inpatient staff, social workers, home care, and other involved service providers.
- Participate in individual and group supervision to develop care management, administrative, and documentation skills.
- Attend staff meetings and CHHUNY trainings and complete required URMC and CHHUNY trainings, Health Updates, time reporting, and other URMC staff requirements.
- Participate in the on-call rotation for GCH@S CHH CMA.
- Perform other duties as assigned.
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
