Health Home Care Coordinator

• 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
• Download consent, CANS and plan of care into the Netsmart care management system
• Provide face to face, including home visits and telephonic contact with enrolled participants and their guardians focusing activities that advance the plan of care
• 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
• Complete all required documentation within set time frames according to CHHUNY, Hospital and Social Work Division standards
• Complete monthly billing sheets accurately reflecting criteria for a billable service
• Collaborate with a variety of community providers and resources to obtain needed services and supports
• Coordinate care with ambulatory and inpatient staff, social workers, home care, and other involved service providers
• Participate in individual and group supervision to further refine and develop care management and administrative/documentation skills
• Attend staff meeting and CHHUNY trainings
• Meet all required URMC and CHHUNY mandatory trainings, Health Updates, time reporting and other URMC staff requirements
• Participate in on-call rotation for GCH@S CHH CMA

• 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
• Experience in providing outreach and care management services for a diverse population of children and their families within the Rochester community
• 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 that meets URMC safe driving requirements and have access to a reliable vehicle

Experience in home visiting and in working with health care professionals in a team approach to care