Health Home Care Coord

Under general direction, but with significant independence, the Children’s Health Home (CHH) Care Coordinator provides comprehensive care management services to patients who are referred by CHHUNY. The CHH Care Coordinator provides comprehensive, care management services in collaboration with the enrolled child’s PCP and other involved providers. Upon receiving assigned referrals, the CHH Care Coordinator 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 Coordinator 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 Coordinator 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.

Responsibilities

Intake referred patients by completing Children's Health Home consent and CANS-NY assessment, develop preliminary care plan, download consent/CANS/plan into Netsmart; Provide face-to-face, including home visits and telephonic contact with enrolled participants and guardians, address compliance with medical and behavioral health, avoid preventable ED visits and hospitalizations, provide information and referrals to community resources, monitor attendance at health and behavioral health appointments, reassess plans of care as needed, identify situations requiring Incident and Compliance reporting; Complete all required documentation, monthly billing sheets, meet with Senior Social Worker, Quality Manager and other CMA staff to achieve quality standards; Collaborate with community providers and resources, participate in team and patient meetings, coordinate care with ambulatory and inpatient staff, social workers, home care, and other service providers; Participate in individual and group supervision, attend staff meetings and CHHUNY trainings, meet URMC and CHHUNY mandatory trainings, participate in on-call rotation; 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 NYS driver's license and automobile insurance; Satisfactory driving record that meets URMC safe driving requirements; Access to a reliable vehicle; DL NUMBER - Driver License, Valid and in State with a satisfactory driving record and access to an automobile upon hire required

Nice to have

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; 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 meet pre-employment requirements