Fresh Start Care Manager

JOB DESCRIPTION

Position/Title: Fresh Start Lead Care Manager

Reporting/Department Head:

• FLSA Status Non-Excempt
• EEO Category Administrative

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Our Mission: To improve lives by providing comprehensive, high-quality healthcare to every person in every community that we serve.

Our Vision: CCHN will maintain its position as the leading community health center in the state and become a model for all other healthcare organizations to follow.

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Major Function:

To provide care management to patients with substance use disorders in an outpatient substance abuse medication assisted treatment (MAT) program. Embedded within an integrated behavioral health/primary care clinic in a federally qualified health center, this position collaborates with the MAT physician and other team members on patient assessments, teaching, stabilizations, and monitoring.

He/she will also play a key role in coordinating with other care teams from Outpatient Addiction Recovery Services, Acute Treatment Services (Detox), residential recovery homes, and community resources to support clients through the continuum of addiction care

Qualifications:

• HS Diploma or equivalent
• Bachelors degree in nursing or social work preferred
• One year of relevant experience may be substituted for each year of required education.
• Knowledge of harm reduction philosophy, patient centered counseling, and motivation interviewing techniques.
• Prior experience conducting individual patient education and counselling sessions.
• Demonstrated ability to work collaboratively in a team environment.
• Demonstrated computer literacy in Microsoft and web-based applications.
• Excellent verbal and written communication skills.
• Excellent interpersonal and organizational skills, including problem solving with a team.
• Knowledge of community resources; demonstrated ability to network and build strong relationships with community organizations serving priority populations as identified by the agency and/ or funder.
• Demonstrated ability to working with patients of diverse backgrounds, underserved communities, and co-morbidities

Essential Job Duties:

• Enroll eligible patients into service programs
• Work closely with other staff to identify clients and monitor their linkage and engagement in medical and behavioral care;
• Identify and document barriers clients experience in accessing care and services, and use a strengths-based approach to overcome them;
• Reinforce treatment goals that clients develop with medical care providers;
• Collaborate with staff across CCHN to support clients needs;
• Supporting the patient and prescriber in buprenorphine initiation, stabilization, and maintenance treatment procedures under the supervision of the prescribing provider;
• Track the following of all FreshStart patients:
  • Mental health appointments
  • Laboratory testing
  • UDS
• Assisting members of the health care team in the formulation and implementation of the plan of care;
• Identify providers that would be a good fit to become Waived X providers
• Assisting the prescribing provider in making referrals to community providers for counseling or higher levels of care when needed;
• Maintaining therapeutic relationships with both the patient and the medical provider;
• Overseeing the following patient care components:
  • Care coordination including medication management and treatment monitoring;
  • Must be able to take after hour phone calls daily from patients and other participants;
  • Assist with reporting requirements including documenting data for reports, preparing reports and submitting data to funders;
  • Support substance abuse recovery skills and promote substance free lifestyle;
  • Provides culturally competent service delivery;
• Must demonstrate initiative, creativity, be dependable, reliable and work well independently;
• Upholds ethical standards in accordance with the social work code of ethics or nursing code of ethics;
• Ensure fresh start providers have accurate information, charts are updated prior to patient appointment with provider;
• Works flexible schedule as requested by provider;
• Perform other duties as assigned.

EEO

The above job description is not to be construed as a complete listing of the assignments that may be given to any employee, nor are such assignments restricted to those precisely listed in the description. This job description may be changed at any time at the managers discretion.