49,261 Home Care Agencies jobs in the United States

**Employment Type:**
Full time
**Shift:**
**Description:**
Mercy Home Health (a member of Trinity Health at Home) has a need for a Full-time Physical Therapist. This position is based out of our Lower Philadelphia branch office.
**We are currently offering a $10,000 Sign On Bonus!**
The Physical Therapist consults, evaluates, plans and administers skilled Physical Therapy services prescribed by a physician to homebound patients to restore function, relieve pain and prevent disability following illness, disease, injury, or surgery. Collaborates with Inter-disciplinary team members to assure patient's needs are met, and quality of care is achieved. When acting as the patient care manager, will manage, oversee and provide primary patient care delivery to a select group of patients supporting the patient centered care model, assuring quality and maintaining open communication. Interacts with any and all members of the care group both internal and external to the organization as needed.
Current PA licensure in Physical Therapy. CPR certification required. Bachelor or Master Degree preferred. One year clinical experience and recent home care experience preferred.
**Our Commitment**
Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.
Our Commitment to Diversity and Inclusion
Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.
Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.
EOE including disability/veteran

Job Description
Summary:

• Ref #: D-RN-
• Profession: Registered Nurse
• Specialty: Home Care / Home Health Nursing
• Job Type: Contract/Travel
• Location: Waterford, CT
• Start Date: ASAP
• Duration: 6 weeks
• Schedule: 8 Hours/Day; 32 Hours/Week
• Shift Type: Days
• Rate: Travel: $1,402/32-hours Local: $1,347/32-hours

Requirements:

• Active RN license in Connecticut.
• Graduated from an accredited school of professional nursing. BSN preferred.
• Minimum of one (1) year experience in an acute care setting or equivalent experience

preferred.

• Valid driver's license, insured vehicle, and clean driving record.
• Strong communication and interpersonal skills.

Responsibilities:

• Provide professional nursing care per the State Nurse Practice Act and home health standards.
• Perform and document comprehensive assessments (including OASIS) within 48 hours of referral/start of care.
• Develop, implement, and update individualized Plans of Care.
• Administer medications and skilled nursing interventions to achieve care goals.
• Report changes in client condition and adjust care plans as needed.
• Communicate effectively with physicians, team members, and clients, maintaining accurate and timely documentation.
• Promote quality care, patient safety, and infection control practices.
• Maintain confidentiality and adhere to company policies and procedures.
• Participate in ongoing professional development and mandatory training.
• Supervise home care staff as per policy and perform other duties as assigned.

**Employment Type:**
Part time
**Shift:**
Day Shift
**Description:**
As a Home Care Coordinator at Trinity Health at Home and Mount Carmel Home Care, you'll deliver exceptional, compassionate care to patients in the comfort of their homes. As the area's most comprehensive home care provider, we're known for trusted, high-quality care. Guided by a new vision, innovative strategies, and advanced technology, we're growing and reshaping healthcare. Join us in making a difference!
Why Join Us?
Start Here. Grow Here. Stay Here!
At our core, we believe in building careers, not just jobs. Many of our team members stay with us for the long haul-and for good reason. Our culture is built on support, growth, and opportunity.
**Home Care Coordinator - Mount Carmel East**
**Part time - 24 hours- Tues-Wed-Thursday**
**Must be clinical- RN/LPN/MSW**
As a Home Care Coordinator, you'll play a vital role in advancing Trinity Health at Home's (THAH) mission by facilitating seamless, patient-centered care transitions. You'll be responsible for efficiently coordinating and enhancing the referral process, supporting patients as they transition from acute care settings to post-acute home care. This role is essential in ensuring patients experience smooth, cost-effective, and results-oriented care.
What You Can Expect:
+ **Consistent, Reliable Workloads**
+ **Competitive Pay & Low-Cost Benefits**
+ **Supportive Leadership**
+ **Career Growth Opportunities**
+ **Epic EMR System**
+ **Fast Hiring Process**
+ **Meaningful Work**
+ **Zero On-Call Requirements**
**Qualifications**
+ Outstanding communication and customer service skills
+ Must Be RN/LPN/MSW or Therapist
+ Strong critical thinking and problem-solving abilities
+ Familiarity with Medicare regulations and managed care systems
+ Proficiency in multitasking across various computer systems
+ Current Ohio registration or licensure (preferred)
+ 3-4 years of clinical experience in an acute care environment (preferred)
+ 1-2 years of experience in home care or intake/sales (preferred)
+ Commitment to the mission, code of ethics, and compliance standards of Trinity Health at Home
**About Mount Carmel Home Care**
Mount Carmel Home Care is part of Trinity Health At Home, a national leader in home care, palliative care, and hospice services across 12 states. Together, we combine clinical expertise and innovative technology to help patients achieve their health goals. Join us as we shape the future of healthcare!
**Our Commitment**
Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.
Our Commitment to Diversity and Inclusion
Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.
Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.
EOE including disability/veteran

**Employment Type:**
Part time
**Shift:**
**Description:**
As a Home Care Coordinator at Trinity Health at Home and Mount Carmel Home Care, you'll deliver exceptional, compassionate care to patients in the comfort of their homes. As the area's most comprehensive home care provider, we're known for trusted, high-quality care. Guided by a new vision, innovative strategies, and advanced technology, we're growing and reshaping healthcare. Join us in making a difference!
Why Join Us?
Start Here. Grow Here. Stay Here!
At our core, we believe in building careers, not just jobs. Many of our team members stay with us for the long haul-and for good reason. Our culture is built on support, growth, and opportunity.
**Home Care Coordinator - Mount Carmel St. Ann's**
**Full time**
**Must be clinical- RN/LPN/MSW**
As a Home Care Coordinator, you'll play a vital role in advancing Trinity Health at Home's (THAH) mission by facilitating seamless, patient-centered care transitions. You'll be responsible for efficiently coordinating and enhancing the referral process, supporting patients as they transition from acute care settings to post-acute home care. This role is essential in ensuring patients experience smooth, cost-effective, and results-oriented care.
What You Can Expect:
+ **Consistent, Reliable Workloads**
+ **Competitive Pay & Low-Cost Benefits**
+ **Supportive Leadership**
+ **Career Growth Opportunities**
+ **Epic EMR System**
+ **Fast Hiring Process**
+ **Meaningful Work**
+ **Zero On-Call Requirements**
**Qualifications**
+ Outstanding communication and customer service skills
+ Must Be RN/LPN/MSW or Therapist
+ Strong critical thinking and problem-solving abilities
+ Familiarity with Medicare regulations and managed care systems
+ Proficiency in multitasking across various computer systems
+ Current Ohio registration or licensure (preferred)
+ 3-4 years of clinical experience in an acute care environment (preferred)
+ 1-2 years of experience in home care or intake/sales (preferred)
+ Commitment to the mission, code of ethics, and compliance standards of Trinity Health at Home
**About Mount Carmel Home Care**
Mount Carmel Home Care is part of Trinity Health At Home, a national leader in home care, palliative care, and hospice services across 12 states. Together, we combine clinical expertise and innovative technology to help patients achieve their health goals. Join us as we shape the future of healthcare!
**Our Commitment**
Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.
Our Commitment to Diversity and Inclusion
Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.
Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.
EOE including disability/veteran

Here at BAYADA, we provide you the **flexibility in choosing** where you want to work, who you want to work with, and the hours you wish to work! We currently have openings for Home Health Aides (HHAs) to work 1 on 1 with our elderly clients. Not certified? Not a problem at all! Be sure to inquire about our affordable **certification training program** !
**Pay Rate: $18 per hour**
We have current job openings for HHAs - Home Health Aides in the following Gloucester County locations:
+ **Deptford**
+ **Woodbury**
+ **Glassboro**
+ **West Deptford**
+ **Williamstown**
**BAYADA offers HHAs:**
+ Weekly pay
+ Comprehensive Benefits
+ Scholarship Program (NEW Advance to LPN Program)
+ Short commute times - we try to match you to opportunities near your home
+ Flexible Scheduling
+ Paid time off
+ 24 / 7 on call clinical manager support
**Job Qualifications:**
+ Minimum one year work experience
+ Current HHA - Home Health Aide license listed in good standing
**Responsibilities for HHA's:**
+ Light housekeeping
+ Bathing
+ Toileting
+ Range of motion / exercises
+ Transfers / use of mechanical lifting devices
+ Home Management Tasks: laundry, meal preparation, bed making etc.
+ Assisting with ambulation
+ Medication Assistance
BAYADA recognizes and rewards our HHAs who set and maintain the highest standards of excellence. Join our caring team today!
**As an accredited, regulated, certified, and licensed home health care provider, BAYADA complies with all state/local mandates.**
BAYADA is celebrating 50 years of compassion, excellence, and reliability. Learn more about our 50th anniversary celebration and how you can join in here ( .
BAYADA Home Health Care, Inc., and its associated entities and joint venture partners, are Equal Opportunity Employers. All employment decisions are made on a non-discriminatory basis without regard to sex, race, color, age, disability, pregnancy or maternity, sexual orientation, gender identity, citizenship status, military status, or any other similarly protected status in accordance with federal, state and local laws. Hence, we strongly encourage applications from people with these identities or who are members of other marginalized communities.

• Practice independently in the community as part of an interdisciplinary care team.

• Deliver personalized nursing and care management to patients in their home or care facilities.

• Constantly evaluate evolving patient needs and respond with plan of care adjustments.

Qualifications

• Current license to practice as a Registered Nurse in New York State

• Minimum of one year nursing experience in a medical/surgical environment

• Valid driver's license or NYS Non-Driver photo ID card may be required

• For Hospice Only:

• Wound Care Certification required or willingness to obtain within one (1) year of hire required

• Certification in Hospice and Palliative Care Nursing required

**Responsibilities**
Are you a compassionate and dedicated professional with a passion for helping others achieve their best possible health? Virginia Mason Franciscan Health is seeking a motivated Health Home Care Coordinator to join our innovative team and make a tangible difference in the lives of our members.
At Virginia Mason Franciscan Health, we believe in providing personalized, integrated care that empowers individuals to take charge of their health journey. As a Health Home Care Coordinator, you will be a vital link in this process, working collaboratively with members, providers, and a multi-disciplinary team to assess needs, facilitate access to services, and coordinate comprehensive care across the full spectrum of health, including behavioral health and long-term care.
**What You'll Do (The Impact You'll Make):**
This isn't just a job; it's an opportunity to transform lives. You'll play a crucial role in ensuring our members receive medically appropriate and cost-effective quality care tailored to their unique circumstances. Your day-to-day responsibilities will include:
+ **Holistic Assessment & Planning:** Conducting comprehensive clinical assessments to determine eligibility for case management services, and then collaborating with members, families, and healthcare professionals to develop, implement, and continuously monitor individualized care plans.
+ **Integrated Care Coordination:** Coordinating a wide range of integrated outpatient care services, including assessing barriers to care, identifying vital community resources, and connecting members with specific wellness programs (e.g., asthma, depression management) to enhance continuity of care.
+ **Empowering Through Communication:** Primarily providing care coordination through telephonic communication, in-home visits, and/or direct face-to-face contact. You'll master motivational interviewing techniques and clinical guideposts to educate, motivate, and support members in making positive changes towards desired health outcomes.
+ **Navigating the Healthcare Landscape:** Guiding members through complex healthcare systems, assisting with medication access, scheduling appointments, arranging transportation, and securing necessary medical equipment.
+ **Advocacy and Support:** Acting as a strong advocate for members and their families, connecting them with financial assistance programs, DSHS, charity care, and insurance providers, and ensuring they have the tools and resources to manage their conditions proactively.
+ **Collaborative Teamwork:** Serving as an integral member of the provider and interdisciplinary team, contributing to comprehensive care plans, and providing continuous updates on member progress, status, and any emerging issues.
+ **Accurate Documentation:** Maintaining meticulous documentation of all services provided, interventions, and member progress in accordance with established guidelines and in a timely, comprehensive manner.
+ **Local Travel:** Up to 40% local travel may be required, depending on the complexity of assigned member cases, allowing for direct personal connection and support.
**Qualifications**
**What You'll Bring (Your Expertise & Qualifications):**
We are seeking a candidate who embodies compassion, critical thinking, and a commitment to patient-centered care. To thrive in this role, you will need:
+ **Education & Experience:**
+ A Bachelor's degree in social work, psychology, geriatrics, nursing, behavioral health, or a related field.
+ One year of related work experience demonstrating the requisite job knowledge and abilities.
+ _Preferred:_ Work experience in case management, social work, or discharge planning.
+ _Alternative:_ An equivalent combination of post-secondary education and work experience demonstrating attainment of the requisite job knowledge/abilities may be substituted for the degree requirement.
+ **Licensure/Certifications:**
+ Eligible for Agency Affiliated Counselor prior to hire date, with credential obtained within 60 days of hire.
+ Current healthcare provider BLS certification.
+ **Knowledge & Skills:**
+ Strong understanding of psychosocial and clinical education concepts.
+ Familiarity with professional standards and accepted guidelines for patient care.
+ Knowledge of community resources and applicable regulatory requirements.
+ Understanding of transitional case management concepts, methodologies, and tools.
+ Exceptional communication, interpersonal, and organizational skills.
+ Ability to work independently and as part of a collaborative team.
+ Proficiency in documenting services and maintaining accurate records.
**Why Virginia Mason Franciscan Health?**
At Virginia Mason Franciscan Health, we are dedicated to creating a supportive and dynamic work environment where our employees can flourish. You'll be part of an organization committed to:
+ **Integrated Care:** Contributing to a model of care that truly puts the patient at the center.
+ **Community Impact:** Making a meaningful difference in the health and well-being of individuals and families in our community.
+ **Professional Growth:** Opportunities for ongoing learning and development in a continuously evolving healthcare landscape.
**Collaborative Culture:** Working alongside a diverse and dedicated team of healthcare professionals.
**Overview**
Virginia Mason Franciscan Health has a rich history of providing exceptional healthcare, dating back to 1891. Building upon a legacy of compassionate care and innovation, our organization has evolved over the years through strategic partnerships and integrations to expand our reach and services across the Puget Sound area.
Today, as Virginia Mason Franciscan Health, we remain deeply committed to healing the whole person - body, mind, and spirit - in the communities we serve. This commitment is strengthened by the diverse expertise and shared values brought together through our growth.
Our dedicated providers offer a full spectrum of health care services, from routine wellness to complex disease management, all grounded in rigorous research and education. Our comprehensive network of 10 hospitals and nearly 300 care sites strategically located across the greater Puget Sound region reflects our ongoing commitment to accessibility and comprehensive care.
We are proud of our pioneering medical advances and numerous awards and accreditations that reflect our dedication to excellence. When you join Virginia Mason Franciscan Health, you become part of a team that delivers top-quality, professional healthcare in modern, well-equipped facilities, and contributes to a legacy of service built on collaboration and shared purpose.
**Pay Range**
$26.76 - $39.81 /hour
We are an equal opportunity/affirmative action employer.

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:
Psych SMH Long Term Care
Work Shift:
UR - Day (United States of America)
Range:
UR URCA 207 H
Compensation Range:
$23.51 - $30.16
_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 the Strong Memorial Hospital, Health, and Health Home Care Management Program. 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 will be serving the most complex, high utilizing patients that need comprehensive care management services. Health Home core 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**
+ Under general direction and with considerable independence, 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.
+ Utilizes community and family resources to create sustainable support systems for patients.
+ Develops, reviews and discusses plans with patient and care team, focusing on linking individuals to clinical and social services with system and community providers.
+ Coordinates outreach and engagement activities focused on finding, connecting and retaining patients in Health Home Care Management Services.
+ 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 a comprehensive Care Management Care Plan using person centered practices for each patient.
+ Care plans highlight and support patient goals, objectives and care management interventions intended to increase self-efficacy and increase engagement with community providers that will support the achievement of patient's goals.
+ Periodically reviews and discusses plan with patient and care team focusing on linking the individual to needed clinical and social services with system and community providers.
+ 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 that 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.
+ Performs other responsibilities and projects as assigned.
Other duties as assigned
**MINIMUM EDUCATION & EXPERIENCE**
+ Bachelor's Degree in an appropriate human services field. Required
+ One 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 or an equivalent combination of education and experience. Required
**LICENSES AND CERTIFICATIONS**
+ Must possess and maintain a valid New York State driver's license, have a satisfactory driving record and have access to an automobile. Required
+ Must pass NYS DOH Health Home and URMC background check requirements. Required
The University of Rochester is committed to fostering, cultivating, and preserving an inclusive and welcoming culture 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 characteristic protected by federal, state, or local law (Protected Characteristics). This commitment extends to non-discrimination in the administration of our policies, admissions, employment, access, and recruitment of candidates, for all persons consistent with our values and based on applicable law.
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 are committed to fostering, cultivating, and preserving an inclusive and welcoming culture and are 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.

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):**
777 S Clinton Ave, Rochester, New York, United States of America, 14620
**Opening:**
Worker Subtype:
Regular
Time Type:
Full time
Scheduled Weekly Hours:
40
Department:
Health Equity Prog Support Ofc
Work Shift:
UR - Day (United States of America)
Range:
UR URCA 207 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:**
Provides professional comprehensive care management services to patients of the Strong Memorial Hospital, Health, and Health Home Care Management Program. 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 will be serving the most complex, high utilizing patients that need comprehensive care management services. Health Home core 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.
The position requires a highly motivated professional for the Health Home Care Manager role with the goal of delivering high quality care to health home program participants and families. The Health Home Care Manager will be dedicated to serving clients that are enrolled or eligible for Health Home, including facilitating referrals, performing assessments and interventions for patients and families.
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 Health Home 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.
Demonstrates ICARE* values in each of the major responsibilities.
**RESPONSIBILITIES:**
+ With considerable independence and latitude for action, and under the direction of the Team Leader, the Health Home Care Manager will:
+ Care Management Responsibilities for a Caseload
**Care Management (35%)**
+ Carry a caseload of assigned clients
+ Complete initial and annual comprehensive assessment of medical, behavioral health and social service needs for assigned health home enrollees
+ Collaborate with a variety of community providers and resources to obtain needed services and supports, utilizing community and family resources to create a 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
+ Utilize dashboard and quality metrics to develop care management strategies for difficult to manage patients, educate office staff on patient or office system issues, including communicated patient care inconsistencies between the primary care physicians and referring specialists
+ For patients referred for health home activities, provide outreach focused on finding, connecting and retaining patients in health home care management services as appropriate
+ Proactively seek out potential enrollees to build up caseload (10%)
+ Work collaboratively with the Referral Coordinator to determine appropriate candidates for new referrals, reinforce existing connections to health home services in the community. Coordinate with inpatient nursing staff, physicians, social work, patients, caregivers, Lead Health Home, Excellus and URMC health home care management agencies to mobilize health home services when patients are in the hospital. Work with hospital staff, patients and caregivers to educate them on the benefits of enrolling in the Health Home Program.
**Patient/Family Education (10%)**
+ Work with provider clinical teams as appropriate (e.g. physician, nurse care manager) to provide disease specific education and information regarding community resources
+ Participate in and/or conduct 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 and meet goals
+ Identify and connect patients with community resources to assist with improving compliance with treatment protocols and social issues (e.g. legal aid)
**Documentation (30%)**
+ 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 enrollees' utilization of services, ensuring care is accessible, attended and effective
+ Provide regular data to team/Leader on patient engagement and strategies to improve this
+ In compliance with UR Medicine policies, New York State Health Home regulations, and program expectations, document accurately and timely all interventions into prescribed electronic medical record system(s) to ensure patient safety and timely reimbursement
**Training (5%)**
+ Participate in care management discipline training and other on-call activities as directed
+ Participate in regularly scheduled team meetings, 1:1 supervision with the Leader, and other meetings
+ Participate in cultural competency events and training appropriate to job duties.
+ Provide Care Management Coverage across Program as Caseload permits (10%)
+ Provide care management coverage across the central team or embedded care practices where needed/assigned, in times of absence of assigned Care Manager
**REQUIRED SKILLS & EXPERIENCE:**
+ At a minimum Care Managers will have appropriate education and experience such as a Bachelor's degree and one (1) year related experience; or an associate degree and a minimum of three (3) to five (5) years related 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; or a CASAC with an equivalent combination of education and experience. Care Managers providing health home service to Children or those with serious mental illness receiving Health Home Plus services must have a Bachelor's degree. Master's degree in human service field preferred.
+ Strong ability to quickly build relationships with ambulatory and hospital staff, patients, caregivers and other key stakeholders
+ Previous work experience in clinical setting, education, population health initiatives or care management highly desired
+ Ability to work independently with excellent communication and demonstrated project management skills
+ Demonstrated ability to maintain expected productivity standards
+ Exceptional judgment and ability to learn the needs of different components of the UR Medicine Enterprise
+ Instinctive capability to foster an inclusive, collaborative work environment
+ Excellent verbal, written and interpersonal skills
+ Proficiency with Microsoft Office programs (Outlook, Word, Excel, Access) and ability to learn new software as needed (Netsmart, eRecord)
+ Must possess Valid NYS driver's license and automobile insurance, have a satisfactory driving record, and have access to reliable vehicle that enables fulfillment of the position's travel requirements.
+ Must pass NYS DOH Health Home and URMC background check requirements.
**Reports to:**
+ URMC Embedded Health Home Team Leader
**Training / Certification Expectations:**
+ This position requires an annual re-certification in HIPAA awareness and annual renewal of an ICARE Commitment contract.
*For more on the ICARE values go to: This document describes typical duties and responsibilities and is not intended to limit management from assigning other work as required.
The University of Rochester is committed to fostering, cultivating, and preserving an inclusive and welcoming culture 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 characteristic protected by federal, state, or local law (Protected Characteristics). This commitment extends to non-discrimination in the administration of our policies, admissions, employment, access, and recruitment of candidates, for all persons consistent with our values and based on applicable law.
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 are committed to fostering, cultivating, and preserving an inclusive and welcoming culture and are 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.