Full-Time
Health Home Care Coordinator
University of Rochester
Compensation Overview
$23.51 - $30.16/hr
Rochester, NY, USA
In Person
Category
 Medical, Clinical & Veterinary (1) |
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Requirements
- Bachelor’s Degree in an appropriate human services field
- One 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 or an equivalent combination of education and experience
- Must possess and maintain a valid New York State driver’s license, have a satisfactory driving record and have access to an automobile
- Must pass NYS DOH Health Home and URMC background check requirements required
Responsibilities
- 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.
- Under general direction and with considerable independence, 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.
- Utilizes community and family resources to create sustainable support systems for patients.
- Develops, reviews and discusses plans with patient and care team, focusing on linking individuals to clinical and social services with system and community providers.
- Coordinates outreach and engagement activities focused on finding, connecting and retaining patients in Health Home Care Management Services.
- 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 a comprehensive Care Management Care Plan using person centered practices for each patient.
- Care plans highlight and support patient goals, objectives and care management interventions intended to increase self-efficacy and increase engagement with community providers that will support the achievement of patient’s goals.
- Periodically reviews and discusses plan with patient and care team focusing on linking the individual to needed clinical and social services with system and community providers.
- 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 that 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.
- Performs other responsibilities and projects as assigned.
- Other duties as assigned