Care Manager - Salary

Sea Mar Community Health Centers•Everett, WA

23h•Onsite

About The Position

The Care Manager supervises an interdisciplinary care management team assisting high-risk patients with behavioral health and medical concerns to meet complex needs and to achieve better health outcomes. The Care Manager tracks a panel of high risk patients including the efficacy of patient care plans and convenes patient-centered interdisciplinary case reviews to establish effective interventions. The Care Management team consists of the Care Manager, Integration Specialists, Care Coordinators, and Wellness Coaches. This team represents a care continuum spanning direct care within the medical clinic into the community where the patient receives assistance generalizing and applying self-management skills. The Care Manager is responsible for assigning to the team tasks of timely and effective screening and assessment, health action care planning, and referrals to and communication with both internal service providers and community-based resources. Screenings may pertain to functional abilities, daily self-management skills, level of activation, depression, anxiety, drug and alcohol use, and other screenings when indicated (examples may include PHQ-9, GAD-7, PAM/CAM, KATZ ADL, AUDIT, DAST, Pain, Fall Risk, etc.). The Care Manager will also assign team members to provide motivational based wellness coaching which includes increasing patient understanding of referrals and consequent referral follow-through that will lead to better health outcomes. Care Management team members will create with the patient a health action plan setting self-management goals and will help the patient increase his/her level of activation to meet these goals. The Care Manager will assign team members to either work within the medical clinic providing SBIRT, behavioral health interventions, and activation based groups (ex: CDSMP) or to provide community-based support such as care transition assistance from the hospital, follow-up in the home, as well as community based care coordination, case management, health coaching, and patient and care giver support in order to facilitate patient progression.

Requirements

Experience working with underserved, transient populations.
Understanding of behavioral health concerns that compound self-care of medical diagnoses, and an understanding of chronic medical conditions that can in turn lead to depression and other mental health concerns.
Experience working with substance use disorders, chronic mental illness, and crisis intervention.
Working knowledge of chronic disease management interventions and evidence-based chronic care guidelines.
Ability to supervise and train new or current integration specialists, care coordinators, Wellness Coaches and/or volunteers regarding Care Management duties.
Ability to educate staff on the psychosocial needs of each patient served.
Ability to work through brief patient contacts and make quick and accurate clinical assessments of mental and behavioral conditions.
Ability to connect well and maintain effective relationships and professional rapport with patients and other members of the care team.
Ability to actively engage patients in therapeutic alliances.
Strong communication skills.
Good knowledge of psychopharmacology.
Working knowledge of diagnostic tools (DSM V and/or ICD-9/10).
Good knowledge of medical terminology.
Experience working with safety net providers within the community and knowledge of community resources.
Good working knowledge of the RSN mental health system structure and regulations.
Ability to work with an interdisciplinary care team including medical providers, nursing staff, care coordinators, behavioral health and support staff and to facilitate care transitions between the medical home, behavioral health, dental, preventive health, and community resources.
The ability to work effectively with all persons and groups with an open mind towards cultural differences and knowledge of cultures.
An understanding of chemical dependency treatment and an ability to coordinate mental health services with substance abuse treatment providers.
Comfort with the pace of primary care and pace of change within this large organization.
A high degree of flexibility to manage the changes and shifts that accompany health care reform and transformation of a Sea Mar Care Management model.
The ability to be a team player within a large organization.
Able to understand that a local view must also accommodate a state-wide view.
The Care Manager must sign a permanent oath of confidentiality covering all patient related information.
Must pass a Washington State Patrol background check.
MSW, MA, MS in counseling or similar human service field or RN with social service experience.
Bachelor’s level education with three years of care coordination or case management experience and supervisory experience will be considered.
Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals.
Ability to write routine reports and correspondence.
Ability to speak effectively before groups of customers or employees of organization.
Typing proficiency of at least 35 wpm.
Fluency in computer applications such as Microsoft Office.
Ability to learn new programs as may pertain to use of electronic health records.
Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals.
Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.
Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists.
Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
Must have and maintain a current TB test.
Must be current with standards health immunizations.
Must have CPR certification.
Must have a WA driver license.

Nice To Haves

Prior exposure to brief, structured counseling techniques is desired (e.g. Motivational Interviewing (MI), Behavioral Activation, Problem Solving Treatment in Primary Care (PST-PC), CBT).
Bilingual English/Spanish preferred.
Licensure or Associate licensure with WA Department of Health is preferred.
Licensure with WA Dept. of Health strongly encouraged.

Responsibilities

Provides team supervision regarding care management and care coordination to all team members.
Receives panel of high risk patients referred either by Sea Mar Care Team, or through contractual basis with managed care organizations.
Assigns clinically appropriate level of care coordination for each patient.
To support an interdisciplinary approach, manager monitors clinical supervision of medical site Integration Specialist (I.S.) by Behavioral Health department (one hour/week) and/or if Care Manager is a licensed behavioral health clinician, Care Manager may provide behavioral health clinical supervision to the medical site I.S.
Provides outreach to community partners and specialists as appropriate to enlist their collaboration in care management services at Sea Mar (ex: forming sound relationship with local hospital).
Conducts with patient any contractually mandated screenings and optional screenings when indicated to identify care needs.
Reviews electronic health record to identify potential care needs and/or reviews PRISM database for the same.
Conducts and/or assigns patient assessments, and creates a Care or Health Action Plan (HAP) with the patient or their caregiver.
Initiates care plan and on-going care coordination and case management.
Coordinates/facilitates communication between patient, primary care physician, specialist, psychiatrist or any other care provider, care coordinator, or case manager or agency involved in patient care.
Monitors patient (in person or by phone) for changes in severity of symptoms, changes in life circumstances compounding self-care abilities, and medication side effects and encourages patient to relay, (or relays when needed), this information to the medical provider and/or specialists of other disciplines.
Assists with Care Transition when patient has been admitted to hospital (ex: may attend discharge planning meeting at hospital; meet with patient and caregiver in home immediately after discharge to prepare for PCP/Nurse visit).
Works with the patient to integrate self-care into their activities of daily living.
Provides outreach to assist patient with generalizing and applying self-management skills in their home or community.
Provides groups such as Chronic Disease Self-Management Program (CDSMP) in clinic or in community.
Attends huddles at the medical clinic when a high-risk patient is identified as needing additional attention and/or sends patient message to MD regarding possibility of attending appointment with patient.
Maintains all appropriate releases of information.
Has excellent knowledge of mental health, substance abuse, employment, and housing and any other community resources and connects patient to resources as appropriate.
Receives reports of patient referrals and when patient is struggling to follow through with a referral, assigns follow up coaching for activation and patient support.
Uses motivational interviewing and behavioral activation techniques with patients as an adjunct to other treatments to assist the patient to achieve HAP goals and progression toward patient activation.
Completes relapse prevention plan with patients who are in remission or have achieved high activation.
Demonstrates knowledge and skills necessary to provide care appropriate to the age of the patients served.
Initiates and facilitates Care Management meetings with Care Management team, and as needed both medical and psychiatric providers (or other identified members Sea Mar service teams) focusing on patients whose complex needs require additional attention.
Receives and implements direction from Manager of Integrated and Collaborative Care Programs (MICCP) regarding projects and tasks assigned to Care Coordinators, Integration Specialists, and Wellness Coach.
Attends community partner meetings as appropriate for Care Management and care coordination (government or county agency meetings).
Effectively communicates to MICCP any developments in community relationships, personnel issues, programmatic issues.
Documents all encounters according to organizational policies and procedures as directed by MICCP and gathers and monitors outcome measurements.
Actively uses any computer applications including Allscripts or other electronic health records or registries as contractually mandated or as directed by MICCP.
The Care Manager will train team members and may assign delegate to provide guidance for newer members.
Other duties as assigned.