Responsibilities **Overview:** Under general direction, but with significant independence, the Care Manager provides comprehensive care management services to adults over 19 years of age assigned to the Complex Care Center (CCC) by the Greater Rochester Health Home, the Health Home of Upstate NY, or providers within the center. The Complex Care Center is a comprehensive interdisciplinary medical home for adults with pediatric onset chronic disease providing primary care, dental services, behavioral health, nutrition, and other clinical services at 905 Culver Road. The Care Manager is responsible for overall management and coordination of the enrollee's care plan which encompasses medical/behavioral health and social service needs and goals. The Care Manager will perform professional, consultative, technical, investigative, advisory, and education activities for patients and families, site staff, and collaborative community agencies. Consistent with Medical Home and NYS regulations and policies for the provision of health home services, conduct data analyses to track patient compliance with treatment protocols and perform non-clinical interventions to assist patients in developing service plans to overcome barriers which prohibit compliance with medical care plans. The Care Manager will communicate and collaborate regularly with patients, physicians, community agencies and office staff with respect to patient compliance, service and care plans and provide assistance. Demonstrates ICARE"' values in each of the major responsibilities. **NOTE: This document describes typical duties and responsibilities and is not intended to limit management from assigning other work as required.** **Major Responsibilities:** **35% Care Management, Utilization of Sen-ices and Outreach:** With significant independence and latitude for action serve as liaison, data coordinator, and patient advocate between the CCC practice team, specialists and community agencies to assist and educate patients in overcoming barriers to treatment which includes: + Provide regular data to team on patient compliance and strategies to improve patient compliance + Documentation in required state and center databases on patient utilization and care management activities. + Escalate case management when medical assessment is needed. + Provide disease specific education and information regarding community resources. + Ensure diagnostic, post-hospitalization and specialty referrals are executed, results received and acted upon. + Request and coordinate team and patient meetings as needed or requested by patient/family and/or team. + Complete initial comprehensive and subsequent annual assessment for medical/behavioral health and social services needs for all assigned enrollees. + Provide outreach and engagement activities focused on finding and connecting enrollee to needed services for assigned clients. + Provide outreach and engagement activities focused on retaining enrolled clients. + Monitor assigned enrollees' utilization of services, ensuring care is accessible, attended and effective. + Collaborate with a variety of community providers and resources to obtain needed services and supports, utilizing community and family resources to create sustainable support systems. + Participate in on-call activities as directed/scheduled by Program Coordinator. + Participate in regularly scheduled team meetings as prescribed by the Center's policy. **35%** Provide outreach for patients referred for health home activities, focusing on finding, connecting and retaining patients in health home care management services. Outreach activities include: + Patient finding and health home enrollment. + Assists patient and family in developing service plan goals. + Develop a comprehensive service plan using person-centered practice for assigned enrollees. + Provide a periodic review of the Service Plan as prescribed by Health Home Regulations. + Frequent non-medical management coaching, education and follow-up visits and phone calls to patients to monitor progress and identify new barriers or concerns. + Assist with financial or other social issues which may provide barriers to patient compliance. + Provide education/guidance to patient and family on tools to manage chronic illnesses, develop individual and web-based tools and resources to improve compliance. + Identify and connect with community resources to assist with improving compliance with treatment protocols and social issues {legal aid). + Monitor use of Emergency and Inpatient services, supporting the enrollees in keeping all aftercare appointments and addressing barriers. + Monitor and encourage enrollees to follow treatment recommendations. + Identify and address barriers to care in conjunction with the service providers, enrollee, and community supports. **10%** In compliance with hospital policy, and Department of Health Home regulations, accurately, and timely, document all medical home health interventions into prescribed electronic medical record systems. **10%** Participate in patient care conference to develop care management strategies for difficult to manage patients, educate office staff on patient or office system issues, patient communicated inconsistencies between the primary care physician and referring specialists. **10%** Monitor practice quality indicators dashboard and reporting to ensure compliance with medical home accreditation, meaningful use including: + Assist with report design. + Conduct data analyses and make recommendations for improvements at team conferences. + Organize and direct practice, agency and community-based specific meetings to report outcomes, compliance; non-compliance and modifications with treatment or service plans. Make recommendations related to modifying treatments based on results. **Requirements:** Bachelor's degree with major course work in an appropriate health, social or technical field, two to three years of related experience; or an equivalent combination of education and experience. **Required Competencies:** Significant knowledge and experience of care coordination and case management services for patients who have complex, high utilizing and costly chronic diseases who are at high risk for not accessing necessary and appropriate level of health services to manage their disease. Proficient in coordination of medical insurance applications for patients. Proficient in using Microsoft Office suite including Word, Excel and Access to develop reports and analyses. Ability to work independently with excellent communication and demonstrated project management skills. Comfortable working with patients and families in an urban setting with significant chronic disease, difficult social issues and mental illness. Spanish speaking a plus. Clean drivers license for the last 3 years required. Local and regional travel required. Annual health assessment and flu and covid vaccinations required. Proficient in coordination of medical Insurance applications for patients required. Proficient in using Microsoft Office including Word, Excel and Access to develop reports and analyses required. Ability to work independently with excellent communication, decision-making and demonstrated project management skills. Comfortable working with patients and families in an urban setting with significant chronic disease, difficult social issues and mental illness. Spanish speaking a plus. Clean driver's license for the last 3 years required. Local and regional travel required. Annual health assessment and flu vaccination required. **Training/ Certification Expectations:** Incumbent must demonstrate dedication to professional development with at least forty hours of training or development activities annually. + HIPAA Privacy and Security + 4 Department HIPAA Privacy Modules + Minors Training + Sexual Harassment and Discrimination Training + Mandatory In Service + ICARE Contract + ERecord + Netsmart **Supervisory responsibilities:** **None.** **Supervision, accountability and evaluation:** Supervised by the Manager of Community Care Management, Team Lead, and Medical Director. Performance assessments generally occur at the end of the introductory period or as directed by the supervisors. Thereafter, performance assessment will occur on an annual basis. The Care Manager will attend supervision as scheduled by the Manager of Community Care Management. The job description will be reviewed at least annually to provide opportunity for the employee and supervisors to amend the description based on modifications to responsibilities. **Equipment:** Computer, telephone, copier, fax, scanner, printer. **System Access Requirements:** + eRecord + Microsoft Office including Outlook, Excel, and Access + Microsoft Project + Netsmart For more on the ICARE values go to: http://intranet.u rmc-sh. rochester.edu/pat ie nt-experience / pat ie nt-centered - care/icare-values.asp 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. **How To Apply** All applicants must apply online. _EOE Minorities/Females/Protected Veterans/Disabled_ **Pay Range** Pay Range: $43,659 - $58,947 Annually _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._ Apply for Job + Careers + Sign In + New User **Location:** Strong Memorial Hospital **Full/Part Time:** Full-Time **Opening:** **Schedule:**