Full Time 40 hours Grade 053 Social Work - Adult Services

GENERAL PURPOSE:

Under general direction, but with significant independence, the Health Home Care Manager provides comprehensive care management services to patients of URMC OB/GYN practices who are referred by providers, the Greater Rochester Health Home Network (GRHHN),

The Health Home Care Manager provides comprehensive, care management services in collaboration with the perinatal care team. Upon receiving assigned referrals, the Care Manager 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 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 Care Manager communicates and collaborates regularly with patients, perinatal and other medical providers, community agencies and office staff to adapt and refine and address support needed to enhance maternal health outcomes

JOB DUTIES AND RESPONSIBILITIES:

• Intake referred patients by completing a Health Home consent. Complete initial, semi-annual, and annual comprehensive assessment of medical, behavioral health and social service needs for all assigned health home enrollees; as required by GRHHN. Based on assessment develop a plan of care that addresses the needs of the patient to include prenatal, birthing preparation and post – partum care information, access and engagement in health, and behavioral health services as indicated, promote safety and environmental stability and address SDOH issues.

• Provide face to face including home visits and telephonic contact with enrolled participants focusing activities that advance the plan of care, and address compliance with prenatal, postpartum, specialty and behavioral health appointments and avoidance of unnecessary ED and hospitalizations. Provide information and referrals to community resources. Monitor attendance at health and behavioral health appointments and reassess plans of care as needed. Identify situations that require Incident and Compliance reporting and inform the Senior Social Worker immediately. Escalate care management when needed.

• Complete all required documentation within set time frames according to GRHHN, Hospital and Social Work Division standards. Complete monthly billing sheets accurately reflecting criteria for a billable service. Meet with Senor Social Worker and other CMA staff to achieve quality standards.

• 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. Participate in team and patient meetings as needed or requested by patient/family or team. Coordinate care with ambulatory and inpatient staff, social workers, home care, and home visiting programs.

• Participate in individual and group supervision to further refine and develop care management and administrative/documentation skills. Attend staff meeting and HH trainings. Meets all required URMC and HH mandatory trainings, Health Updates, time reporting and other URMC staff requirements.

Other duties as assigned

QUALIFICATIONS:

• AAS degree with a minimum of three to five years’ relevant experience or five –eight years’ experience in providing outreach and case management services to women of reproductive age required.

• Considerable experience in providing outreach and care management services for a diverse population of child bearing women with co – morbidities within the Rochester community. Experience in home visiting and in working with health care professionals in a team approach to care required.

• 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 possess valid NYS driver’s license and automobile insurance, have a satisfactory driving record and have access to a reliable vehicle that enable’s fulfillment of the position’s travel requirements.

• Must pass NYS DOH Health Home and URMC background check requirements.

The University of Rochester is committed to fostering, cultivating, and preserving a culture of equity, diversity, and inclusion to advance the University’s mission to Learn, Discover, Heal, Create – and Make the World Ever Better. In support of our values and those of our society, the University is committed to not discriminating on the basis of age, color, disability, ethnicity, gender identity or expression, genetic information, marital status, military/veteran status, national origin, race, religion/creed, sex, sexual orientation, citizenship status, or any other status protected by law. This commitment extends to the administration of our policies, admissions, employment, access, and recruitment of candidates from underrepresented populations, veterans, and persons with disabilities consistent with these values and government contractor Affirmative Action obligations.

All applicants must apply online.

EOE Minorities/Females/Protected Veterans/Disabled