Collaborative Care Manager

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.

KEY COMPETENCIES:

• Communication Skills

Effectively and respectably communicate with other individuals, whether it be a colleague, patient, or patient’s family member and appropriately enumerate information in a manner easily understood by all parties. We do this to foster a culture of understanding between all parties, especially in complex and difficult situations, to ultimately provide the best care possible to our patients and their families.

• Decision Making

Ability to make the most appropriate decision in a given situation and then taking the next steps to ensure appropriate and timely completion. This requires conflict resolution skills, critical thinking skills, confidence in your ability to make the right decision in most situations. This also includes ability to prioritize your workday appropriately to ensure the most important tasks are completed on time.

• HealthCare Knowledge

Having the drive to keep yourself abreast and up to date on the new breakthroughs in your area of expertise and communicating them to the rest of the team, as appropriate.  This also includes keeping up with your licensure and yearly training requirements within your area expertise along with MAHEC’s organizational training. Finally, the ability to apply the depth of knowledge maintained and gained through this process in real life scenarios as appropriate.

• Interpersonal Skills

Showing the ability to meet difficult situations with grace, professionalism, and understanding. Within your area of expertise, showing respect and showing empathy where appropriate with your colleagues, patients, and their family at all times, even when its most difficult to do so. This is done, in part, by effective listening, being your authentic self, showing responsibility and dependability, and being patient with others.

• Organizational Values

Adherence to MAHEC’s founding principles and incorporating them every day. This includes, among others, having integrity and accountability, reverence for other cultures and equitable practices, ability to manage change, and displaying a clear understanding of organizational dynamics. Doing these things creates a culture where people want to do the best for each other and gives personal ownership towards the goal of helping people in their time of need.

• Problem Solving

Having an analytical mind and ability to work autonomously to solve complex problems that may arise. The wherewithal to think logically through a difficult problem and come to an appropriate resolution for a given issue. This helps to drive continuous improvement by thinking through where we can improve in a novel way. Measures success by understanding where we are currently and where we want to go and then applying those new ideas to affect positive change.

SPECIFIED SKILLS

• COMPUTER
  • Excellent skills in Microsoft Office including Word, Excel, PowerPoint, and database applications required.
• FOREIGN LANGUAGE
  • Spanish speaking skills preferred.

PHYSICAL DEMANDS

• Not Applicable.

SUPERVISORY RESPONSIBILITIES: N/A

EDUCATION AND EXPERIENCE

MINIMUM QUALIFICATIONS:

• Masters or bachelor's degree in social work  
• 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 

PREFERRED QUALIFICATIONS:

• Licensed Clinical Social Worker  
• Four (4) years of experience providing care management, case management, or care coordination services  

REQUIRED LICENSES: 

• Valid North Carolina driver’s license 

SCHEDULE:

Regular attendance on-site is an essential function of this position. Typical business hours are Monday – Friday, 8:00 am to 5:00 pm (or flexed to best meet the needs of the clients and/or the Division); 40 hours per workweek; weekend, holiday, or evening coverage is occasionally required. Work hours will need to be flexible in order to respond to special work assignments, or evening activities, as requested by the team leader.