Health Home Care Coord

University of Rochester•Rochester, NY

27d•$21 - $28

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. Provides professional comprehensive care management services to patients of the Strong Memorial Hospital, Health, and Health Home Care Management Program. 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 will be serving the most complex, high utilizing patients that need comprehensive care management services. Health Home core 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. The position requires a highly motivated professional for the Health Home Care Manager role with the goal of delivering high quality care to health home program participants and families. The Health Home Care Manager will be dedicated to serving clients that are enrolled or eligible for Health Home, including facilitating referrals, performing assessments and interventions for patients and families. Consistent with New York State regulations and policies for the provision of Health Home services, the Health Home Care Manager conducts patient level data analyses to track patient adherence with treatment protocols and performs non-clinical interventions to assist patients in developing service plans to overcome barriers to access and care. The Health Home Care Manager communicates and collaborates regularly with patients, physicians, practice-based clinical teams, community agencies and office staff to adapt, refine and address support mobilization as needed. Demonstrates ICARE values in each of the major responsibilities.

Requirements

At a minimum Care Managers will have appropriate education and experience such as a Bachelor's degree and one (1) year related experience; or an associate degree and a minimum of three (3) to five (5) years related 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; or a CASAC with an equivalent combination of education and experience.
Care Managers providing health home service to Children or those with serious mental illness receiving Health Home Plus services must have a Bachelor's degree.
Strong ability to quickly build relationships with ambulatory and hospital staff, patients, caregivers and other key stakeholders
Previous work experience in clinical setting, education, population health initiatives or care management highly desired
Ability to work independently with excellent communication and demonstrated project management skills
Demonstrated ability to maintain expected productivity standards
Exceptional judgment and ability to learn the needs of different components of the UR Medicine Enterprise
Instinctive capability to foster an inclusive, collaborative work environment
Excellent verbal, written and interpersonal skills
Proficiency with Microsoft Office programs (Outlook, Word, Excel, Access) and ability to learn new software as needed (Netsmart, eRecord)
Must possess Valid NYS driver's license and automobile insurance, have a satisfactory driving record, and have access to reliable vehicle that enables fulfillment of the position's travel requirements.
Must pass NYS DOH Health Home and URMC background check requirements.
This position requires an annual re-certification in HIPAA awareness and annual renewal of an ICARE Commitment contract.

Nice To Haves

Master's degree in human service field preferred.
Previous work experience in clinical setting, education, population health initiatives or care management highly desired

Responsibilities

Care Management Responsibilities for a Caseload
Care Management (35%) Carry a caseload of assigned clients
Complete initial and annual comprehensive assessment of medical, behavioral health and social service needs for assigned health home enrollees
Collaborate with a variety of community providers and resources to obtain needed services and supports, utilizing community and family resources to create a sustainable support system
Request and coordinate team and patient meetings as needed or requested by patient/family and/or team
Escalate care management to practice-based resource when medical assessment is needed
Utilize dashboard and quality metrics to develop care management strategies for difficult to manage patients, educate office staff on patient or office system issues, including communicated patient care inconsistencies between the primary care physicians and referring specialists
For patients referred for health home activities, provide outreach focused on finding, connecting and retaining patients in health home care management services as appropriate
Proactively seek out potential enrollees to build up caseload (10%)
Work collaboratively with the Referral Coordinator to determine appropriate candidates for new referrals, reinforce existing connections to health home services in the community.
Coordinate with inpatient nursing staff, physicians, social work, patients, caregivers, Lead Health Home, Excellus and URMC health home care management agencies to mobilize health home services when patients are in the hospital.
Work with hospital staff, patients and caregivers to educate them on the benefits of enrolling in the Health Home Program.
Patient/Family Education (10%)
Work with provider clinical teams as appropriate (e.g. physician, nurse care manager) to provide disease specific education and information regarding community resources
Participate in and/or conduct frequent non-medical management coaching, education, follow-up visits and phone calls to patients to monitor progress and identify new barriers or concerns
Assist with financial or other social issues that may provide barriers to patient compliance
Provide education/guidance to patient and family on tools to manage chronic illnesses, develop individual and web-based tools and resources to improve compliance and meet goals
Identify and connect patients with community resources to assist with improving compliance with treatment protocols and social issues (e.g. legal aid)
Documentation (30%)
Ensure diagnostic, post-hospitalization and specialty referrals have been executed and results received and acted upon as needed
Document plan of care, patient utilization, care management activities and other required information in state and practice databases
Monitor assigned enrollees' utilization of services, ensuring care is accessible, attended and effective
Provide regular data to team/Leader on patient engagement and strategies to improve this
In compliance with UR Medicine policies, New York State Health Home regulations, and program expectations, document accurately and timely all interventions into prescribed electronic medical record system(s) to ensure patient safety and timely reimbursement
Training (5%)
Participate in care management discipline training and other on-call activities as directed
Participate in regularly scheduled team meetings, 1:1 supervision with the Leader, and other meetings
Participate in cultural competency events and training appropriate to job duties.
Provide Care Management Coverage across Program as Caseload permits (10%)
Provide care management coverage across the central team or embedded care practices where needed/assigned, in times of absence of assigned Care Manager