SBIRT/MENTAL HEALTH CARE COORDINATOR

Gila Regional Medical Center•Silver City, NM

About The Position

Under indirect supervision, the SBIRT / MH Care Coordinator is a culturally competent lay health care worker providing ongoing behavioral support to patients in collaboration with the healthcare team. They work closely with the Medical Doctors, Providers, Registered Nurses, Case Management, clinics and social services agencies. They provide patient care coordination, connection to resources, and support programs to improve patients’ health outcomes and general well-being through education, provision of coordination of care and services.

Requirements

High school diploma or GED
Certification as a Community Health Worker with the NM Department of Health or a Medical Assistant with a preferred minimum of two years of experience.
BLS (America Heart Association) certification within 60 days of hire
Experience directly related to the duties and responsibilities specified preferred.
Proficient in computer skills such as Microsoft Word and Excel.
Basic understanding of medical terminology preferred.
Must be able to work effectively under periods of high stress.
Must be able to multi-task in a fast-paced environment and have excellent organizational skills.
Strong interpersonal and communication skills and the ability to work effectively with a wide range of constituencies in a diverse community.
Knowledge of community agencies and resources.
Working knowledge of multi-system outreach programs related to health care delivery, clinical education, and health-related services.
Knowledge of transportation and other barriers to care that may be encountered by patients.
Skill in use of computers and related software applications, including e-mail.
Creative and analytical thinking

Responsibilities

Patient Engagement:
Build trust and rapport with patients in the Emergency Department and Inpatient Service Departments to facilitate open communication and support.
Assist in providing education on healthy living, disease prevention, and available community resources.
Screening & Assessments:
Administers, evaluates, and scores the New Mexico state approved Healthy Lifestyle Questionnaire (HLQ) and provide brief interventions, and refer to appropriate treatment resources.
Complete medication reconciliation to ensure accurate medication records during transitions of care.
Care Coordination:
Collaborate with the Emergency Department healthcare team to provider brief intervention and referral to treatment for those patients at risk and/or suffering from mental health and substance abuse disorder per NM DOH and CMS requirements.
Collaborate with the Emergency Department healthcare team to provide Mental Health Care Coordination referrals for those patients requiring mental health services per NM DOH and CMS requirements.
Assists in care coordination of patients accessing health related services, including but not limited to mental health, alcohol and substance use treatment, obtaining a primary medical provider, providing health care management instruction, overcoming barriers to obtaining needed medical care and /or social services.
Serve as a liaison between patients, families, and healthcare providers to ensure seamless communication and care transitions.
Connect and collaborate with community resources to assist in improving positive patient outcomes.
Documentation:
Documents all patient encounters and referrals made on behalf of patients into the electronic health record to include patient notes, release of health information, assessments and other medical documents acquired on behalf of the patient.
Documents activities, service referrals, and outcomes achieved by patients in an effective manner
Obtain and document patient home medications, allergies and vital signs into the electronic health record.
Health Education & Advocacy:
Communicates to patients the purpose of the screening, brief intervention, and referral to treatment program and the impact it may have on their wellbeing.
Help patients identify substance use disorder issues that affect their overall health through motivational interviewing.
Provide education on medication management, chronic disease prevention, and recovery resources to patients and their families.
Advocate for patients by addressing barriers to accessing care, such as insurance, transportation, and financial limitations.
Coaches’ patients in effective management of their health conditions and self-care.
Assist patients in understanding care plans and instructions.
Motivates patients to be active and engaged participants in their health and overall wellbeing.
Team Collaboration:
Work closely with physicians, nurses, case managers, social workers, and other members of the healthcare team to ensure comprehensive care for patients.
Participate in team meetings, case reviews, and interdisciplinary discussions to optimize patient outcomes.
Follow-Up & Monitoring:
Facilitates communication and coordinate services between providers and the patients. Coordinates and monitors services, including tracking of patients' compliance in relation to care plan objectives.
Contact patients post-discharge to ensure they are following through with care plans, attending appointments, and addressing any concerns.
Complete patient follow-up post discharge phone calls for Inpatient Services and the Emergency Department escalate concerns to appropriate clinical staff when necessary.
Data Collection:
Collect critical information that impacts patient care, care coordination and outcome measurement.
Demographic Information
Health Lifestyle Data
Screening, Brief Intervention, Referral to Treatment Data
Social Determinants of Health Data
Medical History and Care Plan Data
Care Coordination Data
Patient Feedback and Outcome Data