Job Information
Trillium Health NY Medical Case Manager Care Coordination Grant in Rochester, New York
Purpose: To provide comprehensive and timely high quality services by identifying and linking patients to care that will assist in reducing avoidable health care costs and improved patient outcomes by addressing primary medical, supportive needs, specialist and behavioral health care.
Key Job Responsibility Areas
Care Management
Outreach
Miscellaneous
Detail of Key Job Responsibility Areas
- Care Management
Provide patient-centered, quality driven, culturally appropriate comprehensive care management to patients and their families in compliance with agency policies and funder requirements.
Assist in the reduction of avoidable health care cost specifically; (1) preventable hospital admissions/readmissions and (2) avoidable emergency room visits by providing timely post discharge follow-up and improving patient outcomes that address all identified social determinants of health.
Responsible and accountable for identifying client needs and coordinating all aspects of the patient’s care.
Create, document, execute and update an individualized patient centered plan of care that includes community-based and other social supports services in addition to healthcare services that respond to the patient’s needs and preferences and contribute to achieving the patient’s goals.
Ensure that the plan of care is individualized and clearly identifies goals and timeframes for improving the patient’s health and health care status and include interventions that will produce positive outcomes.
Complete periodic reassessments of the plan of care to (1) reassess the needs of the patient, (2) identify the patient’s progress in meeting their goals and; (3) make changes to the plan of care based on changes in the patient’s need
Provide ongoing monitoring of the care plan, e.g., prevention, wellness, medical, specialist and behavioral health treatment, care transitions and social and community services.
Coordinate and provide access to preventive and health promotion services and other community resources that impact health and well-being.
Build relationships with the patients and all members of the treatment team to support continuity of care and promote health.
Coordinate and participate in regular case review meetings that include all members of the interdisciplinary team
Demonstrate the ability to use the health information technology system to coordinate and link services
Identify available community-based resources and actively manage appropriate referrals, access, engagement, follow-up and coordination of services
Ensure follow-up of tests, treatments, services and referrals incorporated into the patient’s plan of care
Accountable for engaging and retaining clients in care
Support adherence to treatment recommendations
Ensure that the plan of care is completed and updated, and progress notes are completed and submitted to supervisor within the designated time frame.
Promote patient access and identify/support internal referral into agency services including, but not limited to: support groups, housing services, Food Pantry, Transportation, behavioral wellness, substance use treatment, Pharmacy and medical care.
Demonstrate developing knowledge of community resources and support external referrals as needed.
Adhere to all government and funder regulations.
- Outreach
- Responsible, in conjunction with Community Health Educator, for conducting outreach and educating the community, health care providers/clinics, and other agencies regarding Trillium Health Services.
3 Miscellaneous
Requires the ability and commitment to respect and support inclusiveness and diversity, including but not limited to individuals of different backgrounds, cultures, races, ages, sexual orientations, gender identities or expressions, transgender, experiences, opinions, etc.
Requires individual demonstration of commitment to the One Trillium values, behaviors and business impacts and modeling them in the organization.
Responsible for maintaining confidentiality of all patient, client, employee, protected and proprietary information.
Must have access to a reliable vehicle and meet the agency driving policy requirements for this position, including a valid NYS driver’s license and proof of required automobile insurance for the vehicle used.
Responsible for maintaining confidentiality of all patient, client, employee, protected and proprietary information.
Employees are accountable for meeting the performance standards of their departments and must participate as requested in compliance audits, process improvement and quality improvement plans.
Other duties as assigned.
Qualifications
Bachelor’s degree or equivalent experience in health, human or education services and a minimum of one year of qualifying experience including case management or casework with persons who have HIV infection, or other chronic illness, a history of mental illness, homelessness, or chemical dependence is preferred. OR a High School diploma/GED and five years of qualifying experience. Computer proficiency is required. Fluency in Spanish and/or ASL preferred. Experience working with diverse populations preferred. Excellent organizational and time management skills required.
Job Requirements
While performing the duties of this job the employee is required to stand, sit, walk, use hands to finger, handle, or feel; reach with hands and arms, talk and hear. Occasionally the employee must stoop, bend and lift or move up to 25 lbs. Specific vision abilities required include close vision, distance vision, peripheral vision, depth perception and ability to adjust focus.
In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.
Acknowledgement