Come make a difference in the lives of people every day while helping us achieve our mission: To improve the health of our patients and communities by delivering exceptional care, removing barriers, and promoting healthy lifestyles.

ROLE: This individual serves as the central facilitator to patients assigned to their care. Their general function is to guide and coordinate care and collaborate with primary care providers, RNs, MAs, and clinic staff in identifying needs, organizing activities, and organizing plans of care for patients with behavioral health conditions. They are an advocate for the patient and work to link them with health and community resources that provide a range of services, promote self-management, improve health, and reduce disparity. They assist patients to achieve health goals and improve health care outcomes.

DUTIES:

· Serve as a key point of contact for discussing and enrolling patients into the SCHS Health Care Home program (document the patient’s acceptance or denial).

· Work directly with patients and their primary care provider(s) and other clinic team members to build and maintain the patient care plans.

· Manage depression/anxiety measures and follow ups (in clinic or by phone) in accordance with Minnesota quality standards.

· Build relationships with patients, patient’s families, guardians, etc.

· Introduce patients to the wide variety of services available across the organization as well as identifying outside resources and services as necessary.

· Serve as an advocate for the patient in understanding needs surrounding shelter, child care, transportation, safety and other social determinants of health.

· Conduct basic screenings of patients within primary care, including review of barriers to health self-management, depression, stress and substance use.

· Provide health education and coaching to patients and refer patients to other care team members (nurses, patient advocates, primary care provider, outside specialists, etc.) as necessary. Topics discussed may include but are not limited to:

o Medication knowledge, adherence and accessibility

o Benefits of best practice treatment for their chronic conditions

o Encourage the patient to identify and set specific health goals in conjunction with goals set by their care provider(s).

· Carry out structured clinical protocols with patients in person or by telephone.

· Intervene appropriately in crisis prevention and de-escalation.

· Serve as a bridge between the patient and internal and external referrals. May work directly with the referral specialist to connect the patient to external community agencies and referral sources when indicated by the care team.

Maintain and document regular communications with patients in the electronic health record.
Manage and work inpatient and emergency room tracking and facilitate appropriate follow ups as needed.
Manage tracking spreadsheet for reporting and follow up.
Contact enrolled patients on a monthly basis. Make additional inquiries/contacts as needed or requested by the patient and/or their care team.

· Work collaboratively with clinic staff to implement and refine workflows throughout the clinic with goals to improve patient satisfaction and care.

· Continuously seek, build and maintain relationships with community partners and resources.

Attend and participate in staff meetings and committees.
Assist with resolving episode of care for mental health due to non-attendance.
Schedule behavioral health visits according to the established schedule for each provider.

· Determine if patient has existing insurance coverage; discuss payment options and schedule appointment with patient advocate, if necessary.

· Manage wait list on Epic and follow up.

· Ensure patient exam rooms are fully restocked with BH business cards, DV resources, child development resources, post-partum education and self-harm resources.

· Prepare for next day visits through pre-visit planning process to verify if service plans or forms such as PHQ, SDQ, CASII and ECSII need to be updated.

· Enter completed paper work into MN-ITS and ensure paper work is scanned into patients chart.

· Create binders with DV resources for patients and other clinic team members update and refill them when necessary.

· Assist with other duties and responsibilities as assigned.

KNOWLEDGE, SKILLS, AND ABILITIES:

· Confidence, professional judgment, and grace under pressure.

· Works well both independently and as part of a team.

· Exceptional verbal and written communication skills.

· Flexibility--nimble in response to an evolving workload.

· Exhibit good rapport with clients of varying ethnic backgrounds and socio-economic status.

· Able to use office equipment such as computer, phone, fax, telephone, etc.

· Excellent time management and organizational skills; attention to detail.

· Commitment to the SCHS mission and staff values.

MINIMUM QUALIFICATIONS:

· Associate’s degree in human services or a Community Health Worker certificate.

· Familiar with medical and pharmacological terminology.

· Experience working with various Microsoft Office applications—Word, Excel, Outlook, etc.

· Previous experience in and environment that provides direct patient care, case management, and/or patient education.

· Bilingual (English/Spanish) strongly preferred.

WORK ENVIRONMENT AND PHYSICAL DEMANDS:

This position operates in a professional clinic environment. The role routinely uses standard office equipment.

Physical demands include:

· Maintain a stationary position for extended periods while performing essential job duties.

· Movement throughout the clinic, including moving between different areas to perform essential duties.

· Position oneself to retrieve items from low cabinets or plug/unplug devices.

· Must be able to operate typical office equipment such as computers, fax machines, copiers, and telephones.

· Requires effective verbal and written communication skills to interact with team members, clients, or patients and to complete necessary documentation.

· Observe patient presentation to complete mental status exam, observe body language to note in chart.

· Discern and note odor of alcohol or body odor.

Reasonable accommodation can be made for qualified individuals with disabilities to enable them to perform the essential functions of the role.

Care Coordinator jobs

Behavioral Health Care Coordinator