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University of Rochester Health Home Care Manager - 233378 in Rochester, New York

Health Home Care Manager Job ID 233378

Location Strong Memorial Hospital Full/Part Time Full-Time Favorite Job Regular/Temporary Regular Opening

Full Time 40 hours Grade 053 Psych SMH Long Term Care


8 AM-4:30 PM



Provides professional comprehensive care management services aligned with ICARE values to patients of the Strong Memorial Hospital 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, health promotion, comprehensive transitional care, enrollee and family support, referral to community and social supports, use of technology to link services.


50% Under general direction and with considerable independence, performs complex care management services for an assigned caseload of clients 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. Utilizes community and family resources to create sustainable support systems for patients. Develops, reviews and discusses plan with patient and care team, focusing on linking individuals to clinical and social services with system and community providers.

10% Coordinates patient outreach (in person, primary care settings, behavioral health clinics, community settings including patient homes, jail, hospitals, shelters, etc.), management activities and interactions focused on locating, connecting and retaining patients in Health Home Care Management Services.

25% Conducts assessments for enrollees identifying service needs that contribute to developing a patient centered care plan. Develops a comprehensive Care Management service Plan using patient centered practices for each patient that highlights and supports patient goals, care management objectives, intended interventions to increase self-efficacy, and increase engagement with community providers that will support the achievement of these patient goals. Reviews and discusses plan with patient and care team, focusing on linking the individual to needed clinical and social services with system and community providers. Documents patient outreach and services in electronic medical record system and ensures that all documentation is timely, accurate and in compliance with Hospital policies and Health Home regulations. Conducts quality reviews of records regularly.

15% Monitors utilization of services, and works to reduce unnecessary emergency room utilization and inpatient admissions by encouraging enrollees to follow treatment recommendations and keep appointments, supporting patients in transitions of care, supports population health initiatives, ensures that care is accessible, attended and effective, and works with the patient to reduce barriers to treatment. Other related duties as assigned.


Bachelor’s Degree in an appropriate human services field and 2 years of experience providing direct services to individuals diagnosed with serious mental illness, intellectual/developmental disabilities, alcoholism/substance abuse required; or experience effectively linking individuals with services that address social determinants of health required; or an equivalent combination of education and experience required. Must possess and maintain a valid New York State Driver's License, have a satisfactory driving record, and have access to an automobile. Must successfully complete NYS DOH Health Home and URMC required background check.

How To Apply

All applicants must apply online.

The University of Rochester is an Equal Opportunity Employer.