Health Home Care Coord
About The Position
As a community, the University of Rochester is defined by a deep commitment to Meliora - Ever Better. Embedded in that ideal are the values we share: equity, leadership, integrity, openness, respect, and accountability. Together, we will set the highest standards for how we treat each other to ensure our community is welcoming to all and is a place where all can thrive. Job Location (Full Address): 60 Corporate Woods, Brighton, New York, United States of America, 14623 Opening: Worker Subtype: Regular Time Type: Full time Scheduled Weekly Hours: 40 Department: 500108 Health Equity Prog Support Ofc Work Shift: UR - Day (United States of America) Range: UR URCA 207 H Compensation Range: $23.51 - $30.16 The referenced pay range represents the minimum and maximum compensation for this job. Individual annual salaries/hourly rates will be set within the job's compensation range, and will be determined by considering factors including, but not limited to, market data, education, experience, qualifications, expertise of the individual, and internal equity considerations. Responsibilities: Provides professional comprehensive care management services to patients of specific locations and/or programs. Collaborates with health, behavioral health, and social service providers and is responsible for assessing patient's needs, developing and managing care plans with patients enrolled in care management. Special focus in serving the most complex, high utilizing patients that need comprehensive care management services. Services include, but are not limited to: care coordination, heath promotion, comprehensive transitional care, enrollee and family support, referral to community and social supports, use of technology to link services.
Requirements
- Bachelor's degree in an appropriate human services field and 1 year of experience in providing direct services to people with serious mental illness, intellectual/developmental disabilities, alcoholism/substance abuse, or experience effectively linking people with services that address social determinants of health required
- Or equivalent combination of education and experience
- DL NUMBER - Driver License, Valid and in State with a satisfactory driving record and access to an automobile upon hire required
Responsibilities
- Develops a comprehensive Care Management Care Plan that highlight and support patient goals, objectives and care management interventions intended to increase self-efficacy and increase engagement with community providers that support the achievement of patient’s goals. using person centered practices for each patient.
- Interacts with patients via telephonic outreach and in-person encounters, such as primary care settings, behavioral health clinics, home, jail, hospital, homeless shelters, and other community settings.
- Conducts assessments, as appropriate, for enrollees identifying service needs that contribute to developing the patient centered care plan.
- Develops, reviews and discusses plans with patient and care team, focusing on linking individuals to clinical and social services with system and community providers.
- Utilizes community and family resources to create sustainable support systems for patients.
- Performs complex care management services consistent with all URMC and NYS Regulations and Policies for the provision of Health Home Services.
- Establishes and maintains cooperative working relationships with community providers to obtain needed services and support for enrolled patients.
- Coordinates outreach and engagement activities focused on finding, connecting and retaining patients in Health Home Care Management Services.
- Completes timely and thorough documentation of services in electronic medical records in compliance with all hospital policies and Health Home regulations.
- Assists with record reviews and quality initiatives.
- Monitors utilization of services and encourages enrollees to follow treatment recommendations.
- Ensures care is accessible, attended and effective.
- Partners with patients and community providers to reduce unnecessary emergency and inpatient services.
- Supports patient in transitions of care, keeping all appointments and addressing barriers as needed.
- Supports population health initiatives.
- Other duties as assigned.
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Number of Employees
51-100 employees
