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University of Rochester Health Project Coord - 227182 in Rochester, New York

Health Project Coord Job ID 227182

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

Full Time 40 hours Grade 053 Division Transitional Care

Position End Date is 6/30/2021



Under general direction, but with significant independence the Children’s Health Home Care Manager provides comprehensive, care management services in collaboration with the child's care team to a caseload of children assigned to the Complex Care Center by GRHHN, CHHUNY Health Home Programs, or providers within the center. 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 Children’s Health Home 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. Upon receiving assigned children, the Care Manager will provide outreach, engage, enroll, assess develop and implement a care plan that addresses the child's medical, behavioral, and psychosocial 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 children’s 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, parent/guardian, physicians, community agencies and office staff with respect to patient compliance, service and care plans and provide assistance in all of the needed areas. Demonstrates ICARE"' values in each of the major responsibilities.


Clinical Services:

  • Intake referred patients by completing a Children's Health Home consent and by engaging the patient/family in the completion of the CANS- NY assessment.

  • Utilizing information obtained from the CANS and in partnership with the family, develops a preliminary care plan. Care plans will address the unique needs of the child to include physical and mental health, growth and development, education, parenting, safety, stability of the home environment, trauma, and social relationships.

  • Review care plans with the child's care team to assure a shared vision of the goals and issues to be addressed and strategies for meeting goals.

  • Document consent, CANS and care plan in the Netsmart care manager data base, and in Epic.

  • Complete transition assessments.

  • Meet with child/family at intervals that promotes progress on the care plan, meets HH expectations, allows for continuous engagement and offers a level of support needed. Face to face meetings can include home visits, at medical appointments or at community service locations. Continually address barriers for child's utilization and compliance with health and behavioral health needs including transportation, housing, insurance, life sustaining resources and referrals to other community resources/services. Document all activities in the Netsmart system and in Epic.

  • Assume primary responsibility for care coordination with primary, specialty, and behavioral health providers, PCMH care coordinators discharge coordinators, home health care, MCO case managers, CPS, and other involved providers of service.

  • Establish liaison relationships with a broad array of formal and informal community services that offer resources for the Children's Health Home population.

  • Monitor emergency room visits and hospitalizations and reassess service plans as indicated based on these encounters as well as every six months of enrollment.

  • Identify and report suspicions of child abuse or neglect according to SMH and Social Work Division policy.

  • Participate in regularly scheduled supervision and bring all critical clinical and administrative issues immediately to the attention of the assigned supervisor.

  • Complete all required documentation within set time frames and according to Health Home, Hospital and Complex Care Center standards.

  • Coordinate and facilitate care conferences.

  • Attend staff and team meetings.

  • Provide statistical reports and other information relating to productivity and quality assurance activities.

  • Provide clinical coverage in the absence of co-workers.

  • May transport a patient with a family member on occasion if needed to meet a care plan goal.

  • Participate in on- call rotation for Children's Health Home Program


    Complete all required mandated trainings and certification in the CANS, health updates, time reporting and ongoing professional development with focus on cultural sensitivity, patient engagement, motivational interviewing, self-management, health promotion, disease management and other areas related to scope of services.


    Bachelor's degree in Social Work; or an equivalent combination of education and experience.

    Preferred Qualifications:

    The Care Manager must have a bachelor’s degree in a human service field or considerable experience in providing care management services within the community via home visits and a minimum of two years of relevant experience in community based work with diverse populations. In addition, the Care Manager must have a current driving record which reflects the UR Safer Driving program standards in order to transport clients. Bi-lingual/Spanish skill is preferred.

    NOTE: This document describes typical duties and responsibilities and is not intended to limit management from assigning other work as required.

    How To Apply

All applicants must apply online.

EOE Minorities/Females/Protected Veterans/Disabled