As a community, the University of Rochester is defined by a deep commitment to Meliora - Ever Better. Embedded in that ideal are the values we share: equity, leadership, integrity, openness, respect, and accountability. Together, we will set the highest standards for how we treat each other to ensure our community is welcoming to all and is a place where all can thrive. **Job Location (Full Address):** 601 Elmwood Ave, Rochester, New York, United States of America, 14642 **Opening:** Worker Subtype: Regular Time Type: Full time Scheduled Weekly Hours: 40 Department: 500382 Social Work-Peds/OB/Outreach Work Shift: UR - Day (United States of America) Range: UR URC 206 H Compensation Range: $20.99 - $28.34 _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._ **Responsibilities:** GENERAL PURPOSE: 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. **ESSENTIAL FUNCTIONS** + Develops a comprehensive Care Management Care Plan that highlight and support patient goals, objectives and care management interventions intended to increase self-efficacy and increase engagement with community providers that support the achievement of patient’s goals. using person centered practices for each patient. + Interacts with patients via telephonic outreach and in-person encounters, such as primary care settings, behavioral health clinics, home, jail, hospital, homeless shelters, and other community settings. Conducts assessments, as appropriate, for enrollees identifying service needs that contribute to developing the patient centered care plan. + Develops, reviews and discusses plans with patient and care team, focusing on linking individuals to clinical and social services with system and community providers. Utilizes community and family resources to create sustainable support systems for patients. + Performs complex care management services consistent with all URMC and NYS Regulations and Policies for the provision of Health Home Services. + Establishes and maintains cooperative working relationships with community providers to obtain needed services and support for enrolled patients. + Coordinates outreach and engagement activities focused on finding, connecting and retaining patients in Health Home Care Management Services. + Completes timely and thorough documentation of services in electronic medical records in compliance with all hospital policies and Health Home regulations. Assists with record reviews and quality initiatives. + Monitors utilization of services and encourages enrollees to follow treatment recommendations. Ensures care is accessible, attended and effective. + Partners with patients and community providers to reduce unnecessary emergency and inpatient services. Supports patient in transitions of care, keeping all appointments and addressing barriers as needed. Supports population health initiatives. Other duties as assigned. **MINIMUM EDUCATION & EXPERIENCE** + Bachelor's degree in an appropriate human services field and 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 required + Or equivalent combination of education and experience **LICENSES AND CERTIFICATIONS** + DL NUMBER - Driver License, Valid and in State with a satisfactory driving record and access to an automobile upon hire required **EOE Minorities / Females / Protected Veterans / Disabled:** 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. Notice: If you are a **Current** **Employee,** please **log into myURHR** to search for and apply to jobs using the Jobs Hub. Your application, if submitted using this portal, cannot be moved forward. **Learn. Discover. Heal. Create.** Located in western New York, Rochester is our namesake and our home. One of the world’s leading research universities, Rochester has a long tradition of breaking boundaries—always pushing and questioning, learning and unlearning. We transform ideas into enterprises that create value and make the world ever better. If you’re looking for a career in higher education or health care, the University of Rochester may offer the perfect opportunity for your background and goals At the University of Rochester, we commit to diversity, equity, and inclusion and united by a strong commitment to be ever better—Meliora. It is an ideal that informs our shared mission to ensure all members of our community feel safe, respected, included, and valued.