Health Home Care Manager

As a community, the University of Rochester is defined by a deep commitment to Meliora - Ever Better. Embedded in that ideal are the values we share: equity, leadership, integrity, openness, respect, and accountability. Together, we will set the highest standards for how we treat each other to ensure our community is welcoming to all and is a place where all can thrive.

Job Location (Full Address):

777 S Clinton Ave, Rochester, New York, United States of America, 14620

Opening:

Worker Subtype:

Regular

Time Type:

Full time

Scheduled Weekly Hours:

40

Department:

500108 Health Equity Prog Support Ofc

Work Shift:

UR - Day (United States of America)

Range:

UR URC 206 H

Compensation Range:

$20.99 - $28.34

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.

Responsibilities:

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.

The position requires a highly motivated professional for the Health Home Care Manager role with the goal of delivering high quality care to health home program participants and families. The Health Home Care Manager will be dedicated to serving clients that are enrolled or eligible for Health Home, including facilitating referrals, performing assessments and interventions for patients and families.

Consistent with New York State 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 Health Home Care Manager communicates and collaborates regularly with patients, physicians, practice-based clinical teams, community agencies and office staff to adapt, refine and address support mobilization as needed.

Demonstrates ICARE* values in each of the major responsibilities.

RESPONSIBILITIES:

• With considerable independence and latitude for action, and under the direction of the Team Leader, the Health Home Care Manager will:
• Care Management Responsibilities for a Caseload

Care Management (35%)

• Carry a caseload of assigned clients
• Complete initial and annual comprehensive assessment of medical, behavioral health and social service needs for assigned health home enrollees
• Collaborate with a variety of community providers and resources to obtain needed services and supports, utilizing community and family resources to create a sustainable support system
• Request and coordinate team and patient meetings as needed or requested by patient/family and/or team
• Escalate care management to practice-based resource when medical assessment is needed
• Utilize dashboard and quality metrics to develop care management strategies for difficult to manage patients, educate office staff on patient or office system issues, including communicated patient care inconsistencies between the primary care physicians and referring specialists
• For patients referred for health home activities, provide outreach focused on finding, connecting and retaining patients in health home care management services as appropriate
• Proactively seek out potential enrollees to build up caseload (10%)
• Work collaboratively with the Referral Coordinator to determine appropriate candidates for new referrals, reinforce existing connections to health home services in the community. Coordinate with inpatient nursing staff, physicians, social work, patients, caregivers, Lead Health Home, Excellus and URMC health home care management agencies to mobilize health home services when patients are in the hospital. Work with hospital staff, patients and caregivers to educate