Health Home Care Coord

Provides professional comprehensive care management services to patients over 18 years of age assigned to the Complex Care Center (CCC) and/or programs. The Complex Care Center is a comprehensive interdisciplinary medical home for individuals with pediatric onset chronic disease providing primary care, dental services, behavioral health, nutrition, and other clinical services at 905 Culver Road. The care manager will collaborate with medical/behavioral health providers, 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, and use of technology to link to services.

Responsibilities

Develops a comprehensive Care Management Care Plan that highlights and supports patient goals, objectives and care management interventions intended to increase self-efficacy and increase engagement with community providers that support the achievement of patient’s goals. using person centered practices for each patient; 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, reviews and discusses plans with patient and care team, focusing on linking individuals to clinical and social services with system and community providers. Utilizes community and family resources to create sustainable support systems for patients; 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; Coordinates outreach and engagement activities focused on finding, connecting and retaining patients in Health Home Care Management Services; 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 encourage enrollees to follow treatment recommendations. Ensures care is accessible, attended and effective; Partners with patients and community providers to reduce unnecessary emergency and inpatient services. Supports patients in transitions of care, keeping all appointments and addressing barriers as needed. 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; Driver License, Valid and in State with a satisfactory driving record and access to an automobile upon hire required