Care Manager- BHC

Job Description

Job Description

Description :

The Care Manager assumes responsibility and accountability for the management of resources through interdisciplinary collaboration to achieve optimal patient outcomes. They will facilitate and coordinate care between and among internal services and external resources.

Scope of Tasks and Responsibilities :

• Work closely with behavioral health consultants, primary care providers, nurses, and medical assistants in order to evaluate patient’s needs and facilitate appropriate referrals.
• Conduct SBIRTS and provide brief intervention and connection to behavioral health consultants. Document appropriately for billing and compliance purposes.
• Utilize screening tools such as the PHQ-9, GAD-7, SBIRT, AUDIT, and DAST as many patients will require referrals based on the scores on one or more of these measures.
• Meet with patients who meet the criteria for positive SBIRT, mental health referrals, PRAPARE, and other high-risk patients in the clinic setting either as a direct referral / handoff from internal resources to assist the patient in getting connected to resources and / or agency processing.
• Assist patients in problem solving potential issues related to the health care system, financial or social barriers (e.g., request interpreters as appropriate, transportation services or prescription assistance).
• Be the system navigator and point of contact for patients and families, with patients and families having direct access for asking questions and raising concerns. May assume advocate role on the patient's behalf to ensure approval of the necessary supplies / services for the patient in a timely fashion.
• Coordinate care services between Raphael Health Center and any other agencies that the patient was referred in which confidential information is needed to be received or shared (ie. Mental health centers, schools, work, disability office, etc.).
• Ensure that referrals are addressed in a timely manner.
• Coordinate referral to services of multiple providers or health care disciplines including follow-up.
• Identify and build relationships with appropriate community resources to maximize the assistance for patients. Build and maintain a service / program referral inventory to utilize with patients and share with other Providers / Team members when indicated.
• Coordinate ongoing navigation and logistical support for appointment keeping including, but not limited to, pre-calling, transportation and interpretive services to reduce access barriers.
• Maintain appropriate documentation as required including PRAPARE and other social determinates of health specific to behavioral health and high-risk patients.
• Perform data collection and entry, including

o Enter into EMR and care management system all SBIRTS, mental health referrals, PRAPARE, and other high-risk patients for UDS along with any additional visits by provider, education, or other support visits.

o Document appropriately and provide accurate information for billing purposes

Requirements :

Required Education, Certification, Experience and Skill :