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University of Rochester Health Home Care Manager - 220051 in Rochester, New York

Health Home Care Manager

Job ID



Strong Memorial Hospital

Full/Part Time


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Full Time 40 hours Grade 053 Psych SMH Long Term Care




Position Summary:

Provides professional comprehensive care management services to patients of the Strong Behavioral Health, Care Management Program. Collaborates with health, behavioral health and social service providers and is responsible for the development and management of service plans for patients enrolled in a NYS-licensed Health Home who have need for the most complex, high utilizing and costly services and may be at high risk for under-utilizing services.


Under general direction, but with significant independence, provides comprehensive care management services to patients of Medicine in Psychiatry Services who are referred by providers within the practice, the Greater Rochester Health Home Network (GRHHN), or the Health Home of Upstate New York (HHUNY).

Performs professional, consultative, investigative, and advisory and education activities for patients and families, site staff, and collaborative community agencies. Consistent with NYS regulations and policies for the provision of Health Home services the Health Home Care Manager conducts patient level data analyses to track patient adherence with treatment protocols and performs non-clinical interventions to assist patients in developing service plans to overcome barriers to access and care. The Care Manager communicates and collaborates regularly with patients, physicians, community agencies and office staff to adapt and refine and address support mobilization as needed. The Health Home Care Manager demonstrates ICARE* values in each of these major responsibilities.

  • Conducts a comprehensive care needs assessments for Health Home enrollees that includes a delineation of medical/ behavioral health and social service needs.

  • Develops a comprehensive Care Management Service Plan using person centered practices for each patient. Reviews and discusses plan with patient, focusing on linking the individual to needed clinical and social services with system and community providers.

  • Monitors utilization of services and encourages enrollees to follow treatment recommendations, ensures that care is assessable, attended and effective. Monitors the use of costly Emergency and Inpatient services, supports patient in keeping all aftercare appointments and addressing barriers as needed.

  • Completes documentation of services provided in eRecord in compliance with hospital policy and Health Home regulation performs periodic reviews of Comprehensive Service Plans as prescribed by NYS DOH. Assists with record reviews and quality initiatives. Actively participates with education and training programs with UR Home Care Health Home Care Management programs.

  • Coordinates outreach and engagement activities focused on finding, connecting and retaining patients in Health Home Care Management Services.

  • Participate in on-call activities as directed/scheduled by Program Coordinator

  • Complete referrals for all eligible patients for the Health Homes program.

  • Other duties as assigned.


Bachelor’s Degree in an appropriate human services field required and 2 years of experience (4 years preferred) 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.

How To Apply

All applicants must apply online.

EOE Minorities/Females/Protected Veterans/Disabled