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Provides professional comprehensive care management services to patients of specific locations and/or programs. 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 in serving the most complex, high utilizing patients that need comprehensive care management services. 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.
Job Responsibility:
Provides professional comprehensive care management services to patients
Collaborates with health, behavioral health, and social service providers
Assess patient's needs
Develop and manage care plans with patients enrolled in care management
Special focus in serving the most complex, high utilizing patients
Services include care coordination, heath promotion, comprehensive transitional care, enrollee and family support, referral to community and social supports, use of technology to link services
Develops a comprehensive Care Management Care Plan
Interacts with patients via telephonic outreach and in-person encounters
Conducts assessments
Develops, reviews and discusses plans with patient and care team
Utilizes community and family resources to create sustainable support systems
Performs complex care management services consistent with all URMC and NYS Regulations and Policies
Establishes and maintains cooperative working relationships with community providers
Coordinates outreach and engagement activities
Completes timely and thorough documentation of services in electronic medical records
Monitors utilization of services and encourages enrollees to follow treatment recommendations
Partners with patients and community providers to reduce unnecessary emergency and inpatient services
Supports patient in transitions of care
Requirements:
Bachelor's degree in an appropriate human services field
1 year of experience in providing direct services to people with serious mental illness, intellectual/developmental disabilities, alcoholism/substance abuse, or experience effectively linking people with services that address social determinants of health
Valid driver's license with satisfactory driving record and access to an automobile