Health Home Care Coordinator

Rochester, NY


General Purpose:

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


  • 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.

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