Full Time 40 hours Grade 053 Manhattan Square Family Med Responsibilities Position Summary: Under general direction, but with significant independence, the Health Home Care Manager provides comprehensive care management services to patients of Manhattan Square who are referred by providers within the practice, the Greater Rochester Health Home Network (GRHHN), or the Health Home of Upstate New York (HHUNY). The Health Home Care Manager will perform professional, consultative, investigative, advisory and education activities for patients and families, site staff, and collaborative community agencies. 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, physicians, practice-based clinical teams, community agencies and office staff to adapt, refine and address support mobilization as needed. The Health Home Care Manager demonstrates ICARE* values in each of these major responsibilities. Responsibilities: With significant independence and latitude for action, serves as liaison, data coordinator, and patient advocate between the practice team, specialists, community agencies, and the patients to assist and educate patients in overcoming barriers to care. Health Home Care Manager is to: Complete initial and annual comprehensive assessment of medical, behavioral health and social service needs for all assigned health home enrollees Work with practice clinical team (e.g. physician, nurse care manager) to provide disease specific education and information regarding community resources Collaborate with a variety of community providers and resources to obtain needed services and supports, utilizing community and family resources to create sustainable support system Request and coordinate team and patient meetings as needed or requested by patient/family and/or team Escalate care management to practice-based resource when medical assessment is needed Ensure diagnostic, post-hospitalization and specialty referrals have been executed and results received and acted upon as needed Document plan of care, patient utilization, care management activities and other required information in state and practice databases Monitor assigned enrolleesâ™ utilization of services, ensuring care is accessible, attended and effective Provide regular data to team on patient compliance and strategies to improve patient compliance Participate in care management discipline training and other on-call activities sponsored by UR Medicine Home Care Participate in on-call activities as directed/scheduled by Program Coordinator Participate in regularly scheduled team meetings as prescribed by the practiceâ™s policy and other meetings directed by practice management to facilitate collaboration with the practice nurse care manager and other team members. Participate in cultural competency events and training appropriate to job duties. Assist patient and family in developing service plan goals Frequent non-medical management coaching, education, follow-up visits and phone calls to patients to monitor progress and identify new barriers or concerns Assist with financial or other social issues that 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 patient with community resources to assist with improving compliance with treatment protocols and social issues (e.g. legal aid) For patients referred for health home activities, provides outreach focused on finding, connecting and retaining patients in health home care management services. Outreach activities include: Patient finding and health home enrollment In compliance with UR Medicine policy, New York State Health Home regulations and Patient Centered Medical Home regulations, accurately and timely documents all interventions into prescribed electronic medical record systems to ensure timely reimbursement. Participates in patient/outpatient care conference utilizing dashboard and quality metrics to develop care management strategies for difficult to manage patients, educates office staff on patient or office system issues, including communicated patient care inconsistencies between the primary care physician and referring specialists. Qualifications: Bachelorâ™s degree with major course work in an appropriate health, social or technical field and 2-3 year related experience; or an Associateâ™s degree and three to five years related experience; or an equivalent combination of education and experience. Significant knowledge and experience of care coordination and care management services for high-utilizing patients who have complex, costly chronic diseases and are at high risk for not accessing necessary and appropriate health services to manage their diseases. Subscribes to the practiceâ™s philosophy of creating a culturally competent environment by treating patients, families and co-workers in a sensitive manner. 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. Maintains expected productivity standards as prescribed by the practiceâ™s policy. Valid NYS driverâ™s license including access to reliable transportation that enables fulfillment of positionâ™s travel requirements. Proof of insurance to be provided at time of hire and driving record to be provided annually.
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