Health Home Care Coord

University of Rochester; United States; On-site; USD 32,000 - 44,000; Full time

Job summary

The University of Rochester invites applications for a Children’s Health Home (CHH) Care Coordinator in Rochester, NY. Under general direction, you will provide care management to patients referred by CHHUNY, collaborating with PCPs and other providers.

You will assess, develop, and implement care plans addressing medical, behavioral, and social needs; monitor adherence; connect families with community resources; and maintain documentation in Netsmart system.

Qualifications

• Bachelor's degree in an appropriate human services field and 1 year of experience providing direct services to people with serious mental illness, developmental disability, or related fields; experience linking people with social determinants of health required.
• Experience in outreach and care management for diverse Rochester population; home visiting and teamwork with health professionals preferred.

Responsibilities

• Intake referred patients by completing CHH consent and engaging families in CANS-NY assessment.
• Develop preliminary care plans in partnership with families.
• Address physical, mental health, development, education, parenting, safety, and housing needs in care plans.

Skills

Interpersonal skills

Organizational skills

Communication

Education

Bachelor's degree in human services field

Tools

Netsmart care management system

CANS-NY assessment

Job description

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): 905 Elmgrove Rd, Rochester, New York, United States of America, 14624 Opening: Worker Subtype: Regular Time Type: Full time Scheduled Weekly Hours: 40 Department: 500382 Social Work-Peds/OB/Outreach Work Shift: UR - Day (United States of America) Range: UR URCA 207 H Compensation Range: $23.51 - $31.74 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:

Under general direction, but with significant independence, the Children’s Health Home (CHH) Care Coordinator provides comprehensive care management services to patients who are referred by CHHUNY. The CHH Care Coordinator provides comprehensive, care management services in collaboration with the enrolled child’s PCP and other involved providers. Upon receiving assigned referrals, the CHH Care Coordinator will engage, enroll, assess, develop and implement a care plan that addresses the participant’s medical, behavioral and psychosocial/SDOH needs and goals. Consistent with New York State regulations and policies for the provision of CHH services the CHH Care Coordinator conducts patient level data analyses to track patient adherence with treatment protocols and provides non-clinical interventions to assist patients in developing service plans to overcome barriers to access and care. The CHH Care Coordinator communicates and collaborates regularly with patients, pediatricians and other medical/ behavioral health providers, community agencies and office staff to adapt and refine and address support needed to enhance health outcomes.

ESSENTIAL FUNCTIONS

• Intake referred patients by completing a Children’s Health Home consent and by engaging the patient/family in the completion of the CANS- NY assessment.
• Utilizing information obtained from the CANS and in partnership with the family, develops a preliminary care plan.
• Care plans will address the unique needs of the child to include physical and mental health, growth and development, education, parenting, safety, stability of the home environment, trauma, and social relationships.
• Download consent, CANS and plan of care into the Netsmart care management system.
• Provide face to face, including home visits and telephonic contact with enrolled participants and their guardians focusing activities that advance the plan of care, and address compliance with medical and behavioral health .and avoidance of preventable ED visits and hospitalizations.
• Provide information and referrals to community resources.
• Monitor attendance at health and behavioral health appointments and reassess plans of care as needed.
• Identify situations that require Incident and Compliance reporting and inform the Senior Social Worker immediately.
• Escalate care management when needed.
• May transport a patient with patient guardian when needed.
• Complete all required documentation within set time frames according to CHHUNY, Hospital and Social Work Division standards.
• Complete monthly billing sheets accurately reflecting criteria for a billable service.
• Meet with Senor Social Worker, Quality Manager and other CMA staff to achieve quality standards.
• 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.
• Participate in team and patient meetings as needed or requested by 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 further refine and develop care management and administrative/documentation skills.
• Attend staff meeting and CHHUNY trainings.
• Meet all required URMC and CHHUNY mandatory trainings, Health Updates, time reporting and other URMC staff requirements.
• Participate in on-_call rotation for GCH@S CHH CMA.
• Other duties as assigned

MINIMUM EDUCATION & EXPERIENCE

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 Experience in providing outreach and care management services for a diverse population of children and their families within the Rochester community. Experience in home visiting and in working with health care professionals in a team approach to care; preferred. Or equivalent combination of education and experience

KNOWLEDGE, SKILLS AND ABILITIES

Strong interpersonal skill in engaging patients in case management services; strongly preferred. Strong organizational skills, capacity to navigate and document in electronic systems, utilize tracking platforms and communicate concisely orally and in written form; strongly preferred. Must meet pre – employment requirements.

LICENSES AND CERTIFICATIONS

DL NUMBER - Driver License, Valid and in State with a satisfactory driving record upon hire required

The University of Rochester is committed to fostering, cultivating, and preserving an inclusive and welcoming culture to advance the University’s Mission to Learn, Discover, Heal, Create – and Make the World Ever Better. In support of our values and those of our society, the University is committed to not discriminating on the basis of age, color, disability, ethnicity, gender identity or expression, genetic information, marital status, military/veteran status, national origin, race, religion, creed, sex, sexual orientation, citizenship status, or any other characteristic protected by federal, state, or local law (Protected Characteristics). This commitment extends to non-discrimination in the administration of our policies, admissions, employment, access, and recruitment of candidates, for all persons consistent with our values and based on applicable law.

Notice: If you are a Current Employee, please log into myURHR to search for and apply to jobs using the Jobs Hub. Your application, if submitted using this portal, cannot be moved forward. Learn. Discover. Heal. Create.

Located in western New York, Rochester is our namesake and our home. One of the world’s leading research universities, Rochester has a long tradition of breaking boundaries—always pushing and questioning, learning and unlearning. We transform ideas into enterprises that create value and make the world ever better. If you’re looking for a career in higher education or health care, the University of Rochester may offer the perfect opportunity for your background and goals. At the University of Rochester, we are committed to fostering, cultivating, and preserving an inclusive and welcoming culture and are united by a strong commitment to be ever better—Meliora. It is an ideal that informs our shared mission to ensure all members of our community feel safe, respected, included, and valued.