Health Home Care Coord

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.

Responsibilities

Provides professional comprehensive care management services to patients of specific locations and/or programs; Collaborates with health, behavioral health, and social service providers; Assesses patient's needs, develops and manages care plans with patients enrolled in care management; Develops a comprehensive Care Management Care Plan using person centered practices; Interacts with patients via telephonic outreach and in-person encounters and conducts assessments; Develops, reviews and discusses plans with patient and care team, linking individuals to clinical and social services; Performs complex care management services consistent with URMC and NYS Regulations and Policies for Health Home Services; Establishes and maintains cooperative working relationships with community providers; Coordinates outreach and engagement activities to find, connect and retain patients in Health Home Care Management Services; Completes timely and thorough documentation in electronic medical records and assists with record reviews and quality initiatives; Monitors utilization of services and encourages enrollees to follow treatment recommendations; Partners with patients and community providers to reduce unnecessary emergency and inpatient services and supports transitions of care; Supports population health initiatives; Other duties as assigned

Requirements

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; Valid driver license, in state, with a satisfactory driving record and access to an automobile upon hire required