Collaborative Care Manager

Mahec • Asheville, NC

2d

About The Position

JOB SUMMARY: The Care Manager works collaboratively as an active member of the Population Health Care Management Administration and part of an interprofessional primary care team. The role to provide comprehensive, person-centered care management services for patients that include: Patient education Medication management and adherence support Risk stratification Population management Coordination of care transitions Care Navigation and referrals In addition, the behavioral health care manager is a core member of a collaborative care team, including the patient’s Primary Care provider and Psychiatric Consultant. The behavioral health care manager is responsible for supporting an coordinating the mental and physical health care of patients on an assigned patient caseload with the patient’s medical provider, psychiatric consultant, and, when appropriate, other members of the care team. Care Managers will support patients with outreach and scheduled care management. This role will systematically and continuously collect and assess data related to patient health status to develop, execute, and evaluate the plan of care. Required care management activities also include care coordination, health promotion, family support, and referrals to necessary resources and supports. These functions may be performed in community-based settings, home visits, and in MAHEC clinics and remotely. The Care Manager will collaborate with Complex Care Managers and Tailored Care Managers, Extenders (Peer Support Specialists, Community Health Workers), Care Navigators, MAHEC clinical teams, community partners, and other regional and state stakeholders. SPECIFIC RESPONSIBILITIES: Develops outreach and engagement strategies for qualified patients. Conduct assessments, screenings and obtain necessary consents to engage in care management Develop person-centered care plans with the patient, Primary Care Providers and behavioral health care team members and with guidance from supervisor and other clinical experts Collaborate with MAHEC’s clinical departments (Family Medicine, Internal Medicine, Pharmacy, OBGYN, and Psychiatry) and community resource organizations to ensure seamless care coordination/management for the population being served. Provide patient self-management education and bridge resources/services that are supportive of social and medical needs. Support transition planning when patients are admitted/discharged from hospitals or other institutional settings. Closely coordinate care with the patient’s medical provider and, when appropriate, other care team providers. Builds and maintains a full patient caseload by actively identifying patients who qualify for program benefits and initiate's outreach. Systematically track treatment response and monitor patients (in person or by telephone) for changes in clinical symptoms and treatment side effects or complications. Complete referrals for unmet social determinant of health needs Complete medication reviews in partnership with PCP, care team nurses or pharmacists Support medication management as prescribed by medical providers, focusing on treatment adherence monitoring, side effects, and effectiveness of treatment. Provide brief behavioral interventions using evidence-based techniques such as behavioral activation, problem-solving treatment, motivational interviewing, or other treatments as appropriate. Provide or facilitate in-clinic or outside referrals Participate in regularly scheduled (usually weekly) caseload consultation with the psychiatric consultant and communicate resulting treatment recommendations to the patient’s medical provider. Track patient follow up and clinical outcomes using a registry/care management platform. Document patient progress and treatment recommendations to share with medical providers, psychiatric consultant, and other treating providers. Facilitate treatment plan changes for patients who are not improving as expected in consultation with the medical provider and the psychiatric consultant and who may need more intensive or more specialized mental health care. Develop and complete relapse prevention self-management plan with patients who have achieved their treatment goals and are soon to be discharged from the caseload. Work with MAHEC’s Quality Improvement team to improve care management delivery and patient outcomes. Ensure required care management data and metrics are documented, tracked, and reported successfully to meet quality standards and guarantee closure of care gaps. Coordinate Care Team meetings Create a Care Management Crisis Plan and coordinate diversion efforts for patients This role description is a general description of the essential job functions. It is not intended to describe all the duties the Care Manager, Behavioral Health (COCM) may perform.

Requirements

• Communication Skills
• Decision Making
• HealthCare Knowledge
• Interpersonal Skills
• Organizational Values
• Problem Solving
• Excellent skills in Microsoft Office including Word, Excel, PowerPoint, and database applications required.
• Valid North Carolina driver’s license
• CARE MANAGER I MINIMUM REQUIREMENTS Bachelor’s or master’s degree in human services Two (2) years of experience providing care management, case management, or care coordination services Meet North Carolina’s definition of a Qualified Professional per 10A-NCAC 27G.0104
• CARE MANAGER II MINIMUM REQUIREMENTS Licensed Clinical Social Worker Registered Nurse Four (4) years of experience providing care management, case management, or care coordination services
• Regular attendance on-site is an essential function of this position.

Nice To Haves

• Spanish speaking skills preferred.

Responsibilities

• Develops outreach and engagement strategies for qualified patients.
• Conduct assessments, screenings and obtain necessary consents to engage in care management
• Develop person-centered care plans with the patient, Primary Care Providers and behavioral health care team members and with guidance from supervisor and other clinical experts
• Collaborate with MAHEC’s clinical departments (Family Medicine, Internal Medicine, Pharmacy, OBGYN, and Psychiatry) and community resource organizations to ensure seamless care coordination/management for the population being served.
• Provide patient self-management education and bridge resources/services that are supportive of social and medical needs.
• Support transition planning when patients are admitted/discharged from hospitals or other institutional settings.
• Closely coordinate care with the patient’s medical provider and, when appropriate, other care team providers.
• Builds and maintains a full patient caseload by actively identifying patients who qualify for program benefits and initiate's outreach.
• Systematically track treatment response and monitor patients (in person or by telephone) for changes in clinical symptoms and treatment side effects or complications.
• Complete referrals for unmet social determinant of health needs
• Complete medication reviews in partnership with PCP, care team nurses or pharmacists
• Support medication management as prescribed by medical providers, focusing on treatment adherence monitoring, side effects, and effectiveness of treatment.
• Provide brief behavioral interventions using evidence-based techniques such as behavioral activation, problem-solving treatment, motivational interviewing, or other treatments as appropriate.
• Provide or facilitate in-clinic or outside referrals
• Participate in regularly scheduled (usually weekly) caseload consultation with the psychiatric consultant and communicate resulting treatment recommendations to the patient’s medical provider.
• Track patient follow up and clinical outcomes using a registry/care management platform.
• Document patient progress and treatment recommendations to share with medical providers, psychiatric consultant, and other treating providers.
• Facilitate treatment plan changes for patients who are not improving as expected in consultation with the medical provider and the psychiatric consultant and who may need more intensive or more specialized mental health care.
• Develop and complete relapse prevention self-management plan with patients who have achieved their treatment goals and are soon to be discharged from the caseload.
• Work with MAHEC’s Quality Improvement team to improve care management delivery and patient outcomes.
• Ensure required care management data and metrics are documented, tracked, and reported successfully to meet quality standards and guarantee closure of care gaps.
• Coordinate Care Team meetings
• Create a Care Management Crisis Plan and coordinate diversion efforts for patients

Benefits

• MAHEC is a qualifying employer for the Public Service Loan Forgiveness (PSLF) Program. Employees who meet federal requirements may be eligible to have remaining student loan balances forgiven after 10 years of qualifying payments while working full-time at MAHEC.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Number of Employees: 1,001-5,000 employees