University of Rochester Health Home Care Coord - 232427 in Rochester, New York
Health Home Care Coord Job ID 232427Location Central Administration Full/Part Time Part-Time Favorite Job Regular/Temporary Regular Opening
Part Time 20 hours Grade 052 University Health ServiceResponsibilities
Provides professional comprehensive care management services to patients of the University Health Service. Collaborates with primary care, behavioral health and social service providers and is responsible for assessing patient’s needs and 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. Medical 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.
Performs complex care management services consistent with all UHS and NYS Regulations and Policies for the provision of Medical Home Services. Develops a comprehensive Care Management 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.
Develops, reviews and discusses plans with patient and care team, focusing on linking individuals to clinical and social services with system and community providers. 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.
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.
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 UHS 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.
Other duties as assigned
Bachelor’s Degree in an appropriate human services field required
1 years of experience in providing direct services to people with serious medical/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.
or equivalent combination of education and experience required
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 UR background check requirements.
How To Apply
All applicants must apply online.
EOE Minorities/Females/Protected Veterans/Disabled