The Bridges to Wellness (B2W) Program will use an Integrated Care Manager as a critical member on the B2W integrated care team by overseeing all health promotion services and communication and coordination between behavioral health and primary care services. The Care Manager will be responsible to gain information on the whole health of the patient population and well as individual recipients. Other duties include: supervision of B2W staff, member of the Guidance Center of Lea County management team and other duties as assigned.
The Integrated Care Manager is responsible for communicating the consumer’s needs to the providers. The Integrated Care Manager will provide training and support to help providers feel comfortable asking and addressing both behavioral health and primary care needs. The B2W Integrated Care Manager is expected to work closely with the Primary Care Provider (PCP) by coordinating treatment, providing proactive follow-up of treatment response, alerting the PCP when the client is not improving, supporting medication management, and facilitating communication with the psychiatrist regarding treatment changes. The Integrated Care Manager will track behavior health and physical markers in electronic medical records from screening and follow up assessments to identify clients who may subsequently qualify for health promotion services.
The Integrated Care Manager is a member of the Integrated Care Team. They are responsible for running the integrated care team meetings and work closely with the PCP by coordinating treatment, providing proactive follow-up of treatment response, alerting the PCP when the recipient is not improving supporting medication management, and facilitating communication with the psychiatric consultant regarding treatment changes.
Other job duties include: (1) the Identification of high-risk individuals and use of client information to determine level of participation in care management services; (2) assessment of preliminary service needs and treatment plan development, which will include client goals, preferences and optimal clinical and physical outcomes; (3) assignment of health team roles and responsibilities; (4) development of treatment guidelines that establish clinical pathways for health teams to follow across risk levels or health conditions; (5) monitoring of individuals and population health status and service use to determine adherence to or variance from treatment guidelines; (6) and development and dissemination of reports that indicate progress toward meeting outcomes for client satisfaction, health status, service delivery and costs. The Integrated Care Manager is responsible for transitional care from impatient to other settings, including appropriate follow-up. The integrated care manager and other members of the care team collaborates with physicians, nurses, social workers, discharge planners, pharmacists, and others to continue implementation of the treatment plan with a specific focus on increasing the consumers’ and family member’s ability to manage care and live safety in the community, and shift the use of reactive care and treatment to proactive health promotion and self-management. The care manager is responsible for all the care management tasks including offering psychotherapy when that is part of the treatment plan.
Licensed by Regulation and Licensing Department as behavioral health practitioner, clinical social worker, psychologist or psychiatric nurse
CONDITIONS OF WORK:
Hiring and promotion will be accomplished in compliance with Guidance Center’s Personnel Policies and Procedures. This position is exempt under the Fair Labor Standards Act. Requires a minimum 40 hours per week. Bi-lingual preferred and travel is required of employee for fulfillment of duties.