Care Manager

Care Navigators On Demand•Santa Monica, CA

10d

About The Position

The Care Manager assists all patients through the healthcare system by acting as a patient advocate and navigator, guiding the client and family with a road map to quality of life. This role coordinates the continuity of patient care with external healthcare organizations and facilities, including hospital admissions and discharges, and referrals from primary care providers to specialty care providers. The Care Manager evaluates clinical care, utilization of resources, and develops new clinical tools, forms, and procedures. They support and closely coordinate healthcare with the patient's primary care provider and, when appropriate, other treating providers. Responsibilities include screening and assessing patients by completing a psychosocial assessment and developing a care plan, providing patient education about common disorders and available treatment options, and supporting psychotropic or general medication management prescribed by PCPs. The Care Manager documents patient progress and treatment recommendations in the system for easy sharing with PCPs, psychiatric consultants, other treating providers, and family members. They facilitate treatment plan changes for patients who are not improving as expected in consultation with the PCP and the psychiatric consultant, which may include changes in medications or psychosocial treatments or appropriate referrals for additional services. Additionally, the Care Manager facilitates referrals for clinically indicated services outside the primary care clinic, such as social services like housing assistance, vocational rehabilitation, mental health specialty care, and substance abuse treatment.

Requirements

Current unrestricted RN License or LCSW/MSW or Advance degree in Psychology, Social Work or Nursing
Ability to work with patients by telephone or in person.
Experience with assessment and treatment planning for common health disorders, when appropriate.
Working knowledge of differential diagnosis of common mental health and/or substance use disorders, when appropriate.
Familiarity with brief, structured intervention techniques (e.g., Motivational Interviewing, Behavioral Activation), when appropriate.
Demonstrated ability to collaborate effectively in a team setting
Reliable transportation and insurance
Able to receive direction and independently follow tasks through with minimum supervision.
Detailed orientated, able to multi-task and remain flexible with assignments.
Ability to maintain effective and professional relationships with patient and other members of the care team.

Responsibilities

Assists all patients through the healthcare system by acting as a patient advocate and navigator, able to guide the client and family with a road map to the quality of life.
Coordinates continuity of patient care with external healthcare organizations and facilities, including the process hospital admission and discharge and referrals from the primary care provider to a specialty care provider.
Evaluates clinical care, utilization of resources, and development of new clinical tools, forms, and procedures.
Support and closely coordinate health care with the patient’s primary care provider and, when appropriate, other treating providers.
Screen and assess patients by completing a psychosocial assessment and develop a care plan.
Provide patient education about common disorders and available treatment options.
Support psychotropic or general medication management prescribed by PCPs, focusing on treatment adherence, side effects and other complications, and effectiveness of treatment.
Document patient progress and treatment recommendations in the system so they can be easily shared with PCPs, the psychiatric consultant, other treating providers, and family members.
Facilitate treatment plan changes for patients who are not improving as expected in consultation with the PCP and the psychiatric consultant. These may include changes in medications or psychosocial treatments or appropriate referrals for additional services.
Facilitate referrals for clinically indicated services outside the primary care clinic (e.g., social services such as housing assistance, vocational rehabilitation, mental health specialty care, substance abuse treatment).