Health Home Care Coord

Rochester, NY


Under general direction, but with significant independence, the Children’s Health Home (CHH) Care Manager provides comprehensive care management services to patients who are referred by CHHUNY.

The CHH Care Manager provides comprehensive, care management services in collaboration with the enrolled child’s PCP and other involved providers. Upon receiving assigned referrals, the CHH Care Manager 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 Manager 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 Manager 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.


  • 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



  • The CHH Care Manager must have a BSW or bachelor degree in a human service field or equivalent education and considerable experience in providing care management services within the community involving home visits with diverse populations.

  • Strong interpersonal skill in engaging patients in case management services. Strong organizational skills, capacity to navigate and document in electronic systems, utilize tracking platforms and communicate concisely orally and in written form. Must possess valid NYS driver’s license and automobile insurance, have a satisfactory driving record that meets URMC safe driving requirements and have access to a reliable vehicle that enable’s fulfillment of the position’s travel requirements. Must meet pre – employment requirements.


  • 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.

The University of Rochester is committed to fostering, cultivating, and preserving a culture of equity, diversity, and inclusion 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 status protected by law. This commitment extends to the administration of our policies, admissions, employment, access, and recruitment of candidates from underrepresented populations, veterans, and persons with disabilities consistent with these values and government contractor Affirmative Action obligations.

How To Apply

All applicants must apply online.

EOE Minorities/Females/Protected Veterans/Disabled

Pay Range

Pay Range: $43,659 - $58,947 Annually

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.

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Location: Strong Memorial Hospital
Full/Part Time: Full-Time