Company DescriptionThroughout its history, three values – work, wellness, and independence – have remained at the core of Rochester Rehabilitation. Working with a $7 million annual operating budget, the agency serves 2,500 people in the Greater Rochester area living with disabilities, behavioral health issues, and other disadvantages.Job DescriptionTo provide patient-centered, high quality care management services in a timely manner to clients with complex chronic conditions by navigating systems such as primary medical, specialty and behavioral health care, as well as social services.Key Functions:Provides comprehensive care management services including: outreach and engagement; assessment/reassessment; development and implementation of initial and revised individualized care plans; consult with primary care physician, and other care provide(s); identify crisis intervention plan.Provides care coordination and health promotion including: collaborate with service providers and health plans to obtain medically necessary care, share crisis intervention(s) and emergency info; linkage to services to support care and treatment goals/plans; patient education ; self-help recovery and selfmanagement; case reviews; advocate for services and assist with scheduling;collaborate with providers to ensure service delivery; monitor, support, accompany (as indicated) patient to/with scheduled appointments; crisis intervention .Provides comprehensive transitional care including: follow up on notice of ER/hospital/residential/rehab setting admission and discharge; facilitate discharge planning with ER/hospital/residential/rehab setting staff to a safe location with care needs in place; notify service providers of admission/discharge and follow appointment needs; link with community supports; post discharge follow up.Provides members and family support including: care planning with patient/family; patient/family consultation and education around health care needs; patient/family meetings; patient/family referral to peer supports, support groups, social services and other programs as indicated; collaborate with community providers to support service utilization based on patient/family need.Provides referral to community and social support services including: identifying and linking to community supports as needed; assure and assist with access to medical, behavioral health, substance abuse and other community based services as needed.Timely and comprehensive completion of documentation including notes, assessments, tracking tools, etc.Adheres to Company policies and procedures to include being aware of the importance of Corporate Compliance Policies and the Code of Conduct. Staff is responsible for maintaining required certifications and licenses.Attends necessary trainings and inservices, participates in department and agency meetings as required.Performs other related duties as assigned by supervisor/director.QualificationsBachelor’s degree in any of the following: child & family studies, community mental health, counseling, education, nursing, occupational therapy, physical therapy, psychology, recreation, recreational therapy, rehabilitation, social work, sociology, or speech and hearing; ORNYS licensure and current registration as a Registered Nurse and a bachelor’s degree; ORA Bachelor’s level education or higher in any field with five years of experience working directly with persons with behavioral health diagnoses; ORA Credentialed Alcoholism and Substance Abuse Counselor (CASAC).Two years’ experience (a Master’s degree in a related field may substitute for one year’s experience) either:Providing direct services to persons with serious mental illness, developmental disabilities, alcohol or substance abuse; ORLinking persons who have serious mental illness, developmental disabilities, alcohol or substance abuse. Additional InformationTo apply, please complete an online application at the link below:https://www.rochesterrehab.org/jobseekers Our Agencies do not discriminate against employees or applicants in the hiring, promotion, compensation, placement, termination, layoff, recall, transfer, leaves of absence or any other term or condition of employment on the basis of race, color, religion, sex, sexual orientation, gender identity/expression, national origin, age, disability, genetic information, marital status, amnesty or status as a covered veteran, domestic violence victim status, prior arrest and conviction records or any other protected category in accordance with applicable federal, state and local laws.