Primary Purpose:

Under the supervision of the Director of Behavioral Health, the BH Services Care Manager is an essential member of the primary care behavioral health care team. The position is responsible for promoting improved and an integrated care management access for clinic patients who have medical and behavioral health care needs.

This position includes being a single point of contact to coordinate warm handoffs from internal primary care providers and coordinate care for a case load of complex patients with chronic health conditions and behavioral health diagnosis. This position also promotes timely and coordinated internal communications among clinic primary care providers, behavioral health specialists, consulting/treating psychiatrists and patients. In order to maximize patient access and provider productivity, this position also collaborates with clinic staff and assist to coordinate management of provider schedules and client appointments, follows up with no shows, facilitates warm hand offs between medical and behavioral health care staff, and provides referrals for community resources to support whole person health.

This position utilizes the electronic health care record and population management tools, to collect data, communicate with providers and produce reports to support collaborative care, improved health outcomes and program compliance. This position will also include management and planning of clinical protocols related to behavioral health and coordinate with the team to ensure integration of medical and behavioral health treatment.

Essential Duties:

Administrative

Accepts and coordinates warm hand-offs of patients between medical and behavioral health providers to facilitate integration of care.

Assists in establishing and maintaining smooth functioning and relationships between primary care providers, behavioral health specialists, and primary care consulting psychiatrists.

Tracks, monitors and reports on BH community resources, Release of Information Requests, etc.

Tracks, monitors, and reports depression, anxiety and/or drug and alcohol screenings within primary care and behavioral health and follows up as directed with patients and/or in assignment of patients for follow up by behavioral health specialists.

Coordinates care for a case load of patients with complex medical and behavioral health diagnosis and ensure coordination of care with internal and external providers to enhance the quality outcomes for complex patients.

Assists behavioral health providers to ensure documents are completed for disability benefits (SSI/SSDI/Welfare); referrals for community based case management services and ensure all eligible patients obtain health insurance.

Is fully knowledgeable of patient eligibility requirements for additional services and assist patients in navigating their care with both in-house and outside providers by facilitating scheduling of visits, identifying barriers to receiving care, and assisting with providing referrals to community and internal resources.

Participates in referrals and coordination of care under the supervision of the BH therapist and psychiatrist for patients who are experiencing a crisis or require a higher level of care to facilitate the referral and to facilitate and confirm contact with the service provider, if further services are needed.

Provides health education and patient instructions as defined by protocol and as appropriate to promote the understanding and adherence to BH screening and treatment as well as in coordination with other appropriate health and wellness education.

Provides sensitive and accurate information to patients, including those being screened and treated for BH conditions, including those patients needing referral to outside providers

Participates in, coordinates, and/or attends and conducts outreach at community events such as health fairs and community forums, as a representative of TVHC, Inc.

Participates in the development in-house reporting and data management including gathering data and the development of reports for the behavioral health department to ensure compliance with behavioral health protocols and internal reporting.

Documents feedback from users (BH, consulting psychiatry, Primary Care Providers, MA's, RN's, external specialty BH providers) on data gathering and works to enhance the overall flow of patient processing for the purpose of better monitoring and tracking of specified health measures (i.e., BH Services care coordination, and chronic health conditions, warm handoffs, completion of BH screening protocol and follow-up, panel management process, consulting psychiatry, BH, and PCP communication processes, etc.)

Maintains high level of respect and confidentiality in handling patient information at all times in accordance with HIPPA and Behavioral Health confidentiality laws.

Works collaboratively with other departments. Promote and support the patient centered medical home. Provides back up to the Behavioral Health support staff team as required based on the staffing needs of the department.

• Ensures accurate and timely documentation in the electronic medical record.

Regular and Reliable on-site attendance is required.

Other Duties:

Performs other related duties as assigned

• Observes safety and security procedures; determines appropriate actions beyond guidelines; reports potentially unsafe conditions; uses equipment and materials properly.
  
  

Minimum Qualification Requirements:

Education:

Bachelor's degree in a Human Services or equivalent required

Bachelor's degree in Social Work (BSW) preferred

Experience:

One or more years of experience within a healthcare facility or social services agency with direct patient care experience required. Experience can be through practicum experience.

One or more years of experience with behavioral health patients preferred.

Skills/Knowledge:

Good crisis intervention / de-escalation skills.

Training and knowledge of mental health, substance abuse / dual diagnosis.

Ability to relate effectively to challenging clients, including mentally ill, chemically dependent, and homeless individuals.

Ability to work independently in an effective manner.

Strong oral and written communication and interpersonal skills.

Ability to work as a team player.

Knowledge and skill in the delivery of community healthcare.

Knowledge of community resources, how to access such, and an awareness of government assistance programs.

Ability to assess and plan in a multi-cultural context.

Professionalism, sound clinical and ethical decision making skills

Ability to demonstrate cultural sensitivity with multi-ethnic populations.

Flexibility in program development and evolution.

Strong organizational skills.

Intermediate ability to use MS Windows including Word, Excel, PowerPoint, EMR, Telehealth, Video-Conferencing, and Access.

Kalihi-Palama Health Center is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.