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Rochester, NY
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Trillium Health, a Federally Qualified Health Center Look-Alike, is a community health center offering access to affordable care for all, with a special focus on meeting the needs of LGBTQ people, communities of color, and underserved populations.

Nationally recognized for outstanding patient-centered care, the team at Trillium Health provides a wealth of knowledge and experience. Our expansive array of services, including testing and treatment, laboratory services, primary and specialty care, and an on-site pharmacy, makes it easier for patients and clients to receive the complete care they need, all in one place.

Our authentic commitment to diversity and inclusion is evidenced through our hiring practices, our employee programs, and our compassion for everyone we serve. Based in downtown Rochester, with satellite locations in Bath and Geneva, and MOCHA centers in Buffalo and Rochester, Trillium is deeply invested in building community. We proudly sponsor many other nonprofit organizations throughout the area and participate in a wide range of community events.

Trillium’s employee-centered company culture and exceptional benefits have contributed to impressive growth in recent years, raising our staff total to more than 250. We hope you will consider joining us on this upward path and becoming a part of the Trillium Health family.
We are currently recruiting for a HARP/HCBS Care Manager, Health Homes.

Health Home Care Management
• Provide person-centered, quality driven, Health Home care management to eligible patients/clients per HHUNY and agency policies and procedures.
• 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
• Build relationships with the patient/client and all members of the care team to support continuity of care and promote health outcomes.
• Coordinate and participate in regular care plan review meetings that include all members of the care team.
• Accountable for engaging and retaining patients/clients in care
• Document each patient/client focused interaction comprehensively and concisely, in accordance with DOH, HHUNY and agency standards.
• Promote patient/client access into internal agency services including, but not limited to: support groups, behavioral wellness, medical care, supportive services and Community Health Initiative Services.
• Responsible for demonstrating professionalism and good judgement when interacting with stakeholders, collaborators, community members, etc.
• Adhere to all government and funder regulations.
• Performs other duties as assigned.

HARP/HCBS Care Management

• In addition to job responsibilities Health Home Care Management as outlined above:
 Complete Functional Consent with HARP enrolled patients/clients approved for Health Home Care Management services.
 Once Functional Consent is obtained, complete the Eligibility Assessment utilizing the Uniform Assessment System within the Health Commerce System to determine HARP enrolled patients/clients’ eligibility for HCBS services.
 Provide HARP/HCBS care management to HARP enrolled, HCBS eligible patients/clients per HHUNY and agency policies and procedures.
 Adhere to all government and funder regulations.
 Performs other duties as assigned.

• 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, experiences, opinions, etc.
• Requires individual demonstration of commitment to the One Trillium behaviors and business impacts and modeling them in the organization.
• Demonstrate developing knowledge of HIV/AIDS, mental health diagnoses and chronic medical conditions.
• Demonstrate developing knowledge of community resources.
• Demonstrate the ability to use Health Information Technology to coordinate and link services.
• Responsible for maintaining confidentiality of all patients, clients, proprietary, and protected information.
• Excellent organization and time management skills required.
• Must have 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.
• Employees are accountable for meeting performance standards of their departments and must participate as requested in compliance audits, process improvements and quality improvement plans.


Bachelor’s degree in social work, psychology, nursing, rehabilitation, education, occupational therapy, physical therapy, recreation/recreation therapy, counseling, community mental health, child and family studies, sociology, speech and hearing or other human services field with a minimum of two years of qualifying experience in providing direct services to people with serious mental illness, developmental disabilities, or substance use disorders; or in linking individuals with serious mental illness, developmental disabilities, or substance use disorders to a broad range of services essential to successful living in a community settings. A Master’s degree in in one of the qualifying education fields may be substituted for one year of experience. Computer proficiency is required. Fluency in Spanish and/or ASL preferred. Must be accustomed to diversity.

Trillium Health offers employment to all employees & applicants. No person shall be discriminated against in employment on the basis of race, age, color, marital status, religion, creed, sex, sexual orientation, gender identity or expression, national origin or ancestry, disability, veteran status, status as a domestic violence victim, genetic condition or predisposition, or any other characteristic protected by law.
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