Health Home Care Coord

📋 Description

• • As a Health Home Care Coordinator at Rochester Electronics, LLC, you will provide professional comprehensive care management services to patients over 18 years of age assigned to the Complex Care Center (CCC) and related programs, playing a vital role in supporting individuals with pediatric onset chronic disease through integrated medical, dental, behavioral health, nutrition, and social services.
• • Day to day, you will develop and manage personalized care plans, conduct assessments via telephonic and in-person outreach in diverse settings (including homes, clinics, shelters, and hospitals), coordinate with medical and social service providers, document services in electronic medical records, monitor care utilization, and support patients in reducing unnecessary emergency and inpatient care while promoting treatment adherence and transitions of care.
• • You will be part of the Division of Transition Medicine at the University of Rochester Medical Center, a team deeply committed to the Meliora—Ever Better ideal, upholding values of equity, leadership, integrity, openness, respect, and accountability in serving high-need, high-utilizing patients through an interdisciplinary medical home model.
• • In this role, you will develop expertise in complex care management, health home regulations, person-centered planning, care coordination across clinical and community systems, and quality improvement initiatives, while contributing to population health goals and gaining experience in navigating healthcare and social service ecosystems for vulnerable populations.