Team Care Case Manager

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Job Title: Team Care Case Manager

Department: Integrated Health, Clinical

Time Commitment: Full-time

Reports To: Integrated Health Coordinator

FLSA Status: Non-exempt

Primary location: All CHWP site

2. POSITION SUMMARY

Community Health and Wellness Partners (CHWP) is an integrated primary care community health center that utilizes a team-based care model, sharing patient-care responsibilities among members of a team. The Team Care Case Manager provides leadership by maintaining an excellent attitude and utilizing leadership by example. As part of this model, the Team Care Case Manager provides relevant interventions under the guidance and supervision of the Assistant Behavioral Health Medical Officer and Behavioral Health Manager and is the primary interface for patients to access community resource services. Responsible for the coordination of ancillary services, community resources, screening for chronic conditions and resource needs, providing brief intervention, referral to appropriate treatment and services, and documentation of care provided. The Team Care Case Manager is also responsible for being a liaison for community agencies as assigned. Supports the coordination activities of all team members engaged in clinical care for patients. Responsible for supporting clinical staff in team-based care and encourages team members to stay focused on the organizations Mission, Vision, and Values.

3. PRIMARY ACCOUNTABILITIES

Achieve Results

• Meet or exceed all measurable standards of care, including overall clinical, quality, and productivity goals.
• Ensure accuracy, efficiency, and appropriate confidentiality with patient charting and related recordkeeping and administrative functions as assigned and are always maintained current and relevant.
• Promote attainment of specified goals through education to patients/families and health care personnel as delegated by the primary care and ancillary services teams.
• Promote and exemplify excellent customer service to ensure that all clients/patients are served with a high level of customer satisfaction and care.

Operational Excellence

• Ensure the delivery of all coordination and care is consistent with all regulatory, accreditation and professional standards, including behavioral health policies and quality initiatives.
• Understand and ensure all practices and procedures related to the delivery of behavioral health and clinical services are consistent with contracted protocols and procedures, regulating entities (HRSA, HIPAA, TJC, PCMH, etc.) professional standards, and that the team-based care model is followed with efficiency.

Relationship Management

• Develop and ensure favorable relationships with all team members, patients, and their families. Achieve commitments from patients to adhere to an effective plan of care, and ensure all patient services are delivered in a caring and professional manner.
• Develop and ensure ongoing, positive relationships and collaboration between members of the team assigned. Ensure the success of team-based care and that relationships with all clinic operations staff are highly respected.

Professionalism & Stewardship

• Serve CHWPs Mission by providing quality, whole-person, patient-centered medical care to anyone and everyone in our community.
• Aspire to CHWPs Vision to change lives within our community by eliminating barriers and providing a standard of healthcare that improves the well-being of the whole person.
• Commit to the Values of CHWP (BLESSED):

Be welcoming

Listen with heart

Educate patients

Serve with excellence

Share best practices

Eliminate barriers

Develop relationships

• Ensure all actions, job performance, personal conduct and communications always represent the organization in a highly professional manner.
• Uphold and ensure compliance and attention to all corporate policies and procedures as well as the overall mission and values of the organization.
• Compliant with HIPAA
• Volunteer to serve the community by offering two (2) hours annually to a community service program.

4. PRIMARY TASKS & DUTIES

• Participates as a member of the team-based care model by being a strong team builder, working to support performance goals related to patient care.
• Administers clinically indicated standard screening and outcome measures instruments (exp. PHQ-9).
• Provides direct behavioral health interventions based on screening outcomes and patient symptoms to patients as indicated and qualified to perform with excellence.
• Will assist in coordinating ongoing care for patients who are at risk for poor health outcomes.
• Perform comprehensive bio-psychosocial assessment. Conduct follow-up as appropriate based on results of evaluation.
• Responsible for coordinating referrals for Home Health/Hospice, Long Term Care Facilities, and other social services available in the patients community.
• Assist patients with determining eligibility for health coverage programs and other programs as needed. This includes assistance with forms, making initial contacts and appointments for the patient. Follow-up with the patient to ensure linkages to services are made.
• Supports patient practice of skills learned in consultation with Primary Care Providers, Behavioral Health Providers, Behavioral Health Psychiatric Providers, and other ancillary providers.
• Supports collaboration of primary care teams and behavioral health staff regarding symptom management.
• Maintains up-to-date contact information for commonly used community resources.
• Develop and maintain collaborative working relationships with community providers of services.
• Assists in delivery of group visits, as assigned.
• Is accessible in person, over the phone, or via telehealth technology by being present and available to CHWP clinical teams during clinic hours.
• Participates in quality strategies to evaluate compliance with standards and identify opportunities to improve patient outcomes.
• Aids Behavioral Health Manager in capturing program evaluation and fidelity measures.
• Attends all meetings, patient conferences, planning sessions related to quality assurance, patient care and other related topics within the health center as assigned.
• Participates in continuing education to maintain best practices.

5. ESSENTIAL FUNCTIONS/KEY COMPETENCIES

• Competent communicator; effectively, positively, clearly, and concisely.
• Contributes to and supports clinic day-to-day activities.
• Supports team members to meet practice standards of quality and efficiency, supporting the implementation of quality program improvement processes and initiatives.
• Implements training programs within the Team Care model.
• Documents and supports population health initiatives.
• Handles appropriate positive and negative feedback to motivate, encourage and develop team-based care.
• Serves as a member on one of CHWPs organizational committees, as requested.
• Adheres to evidence-based practices such as brief interventions and clinical quality.
• Demonstrate a high level of skill in building relationships and customer service.
• Demonstrate interpersonal savvy and influence skills in managing difficult patients.
• Demonstrate a high degree of knowledge and competency in integrated behavioral health practices.
• Demonstrate a high level of problem-solving skills to better serve patients and staff.
• Strong attention to detail and accuracy.
• Excellent verbal and written communication skills.
• Ability to implement and evaluate operational and administrative processes.
• Participates in aspects related to quality compliance, improvement, and risk management for a community health center.
• Engages in certification projects, i.e. The Joint Commission
• Engages in all compliance requirements of Community Health & Wellness Partners
• Any and all other duties as assigned by Leadership, Management or Administration.

7. SUPERVISORY RESPONSIBILITIES

None.

8. WORK ENVIRONMENT

The work environment characteristics are those for a normal community health center environment (ambulatory primary care office). Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Work may require occasional Saturday and/or evening hours.

Work hours

Full-time, non-exempt hourly position. Generally, a 40-hour work week is required for full-time; part-time as agreed upon by parties; hours are subject to change. Office hours vary by site Monday through Friday. Some Saturdays and after business hours work may be required. Assigned meetings and travel are a part of the position. Remote work /Telecommuting may be available on a limited basis at the discretion of the Integrated Health Coordinator or Manager. Paid Time Off (up to 150 hours 1st year), six paid holidays off while offices are closed, and birthday/personal day off.

Wages

Starting wages for Team Care Case Manager will be negotiable based on Community Health & Wellness Partners pay policies and factors such as education and experience, national and state average compensation recommendations based on location and region. Benefits begin on date of hire. We offer medical, vision, dental, life, LTD and many other voluntary benefits to choose from.

Introductory Period

Ninety (90) calendar days probationary period. The successful completion of the introductory period does not alter the at-will employment status.

9. EQUAL OPPORTUNITY EMPLOYER

Community Health & Wellness Partners is an Equal Opportunity Employer.

6. QUALIFICATIONS AND REQUIREMENTS

Education

• Bachelors degree in social work or related field.
• Preferred one (1) to three (3) years of experience in behavioral health or integrated primary care practice.
• May accept new graduates.

Certificates and Licenses

• Valid Ohio driver's license.
• Active Social Work or Counselor License within the State of Ohio, preferred.

Professional

• Demonstrates expertise in relevant behavioral health practices, protocol, trends and best practices in clinical areas assigned.
• Demonstrates knowledge and success in effecting overall clinical operations.
• Experience/Knowledge of accreditation processes and requirements, as well as all federal, state and local regulations and standards associated with the delivery of care in a community health center environment.
• Ability to manage multiple responsibilities and emergency situations successfully.
• Proficiency in knowledge of office management, use of computer, software packages, and office machines.

Physical/Environmental

• Occasional lifting of 40 50 lbs. and pushing of 5-20 lbs.
• Sitting, standing, and walking approximately 80% of the time
• A medium to high level of manual dexterity required.
• Bending and reaching approximately 20% of the time
• Normal accessibility and mobility throughout the region required.
• Normal overtime/extended work hours