Health Home Care Coord

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

Job summary

University of Rochester is seeking a Health Equity Program Support Office professional to provide comprehensive care management for patients in designated locations and programs. You will assess needs, develop care plans, and coordinate with health, behavioral health, and social service providers to improve patient outcomes.

The role focuses on complex, high-utilization patients, involving care coordination, health promotion, transitional care, and linkage to community supports.

Qualifications

• Bachelor's degree in an appropriate human services field and 1 year of direct services experience
• Driver license valid and in-state with reliable driving record

Responsibilities

• Provides professional comprehensive care management services and develops patient-centered care plans.
• Collaborates with health, behavioral health, and social service providers and links patients to clinical and community resources.
• Performs telephonic outreach and in-person encounters across multiple settings (primary care, behavioral health, jail, homeless shelters).
• Completes documentation of services in electronic medical records per hospital policies and Health Home regulations.
• Supports transitions of care and population health initiatives.

Skills

Care management

Communication

Patient outreach

Documentation

Education

Bachelor's degree in human services

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): 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 - $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:

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. ESSENTIAL FUNCTIONS 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.

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 Or equivalent combination of education and experience

LICENSES AND CERTIFICATIONS

DL NUMBER - Driver License, Valid and in State with a satisfactory driving record and access to an automobile 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.

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.