Care Manager

Care Manager - Behavioral Health (MSW) CIN *Days (M-F, 8a-5p) - 40hrs/wk Shift: Days General Purpose of Job As part of the Department of Population Health, the Behavioral Health Care Manager (BHCM) will be centrally supporting five primary care practices within the University of Michigan Health-West (UM Health-West) system. Building on a strong foundation of Behavioral Health Integration (BHI), the team will be launching Collaborative Care (CoCM) as a new program, assisting both patients and providers in an integrated care model. Common Duties and Responsibilities As a member of the larger ambulatory behavioral health team, this centralized BHCM will play a vital role specific to rolling out CoCM to improve access for patients with depression, anxiety and other mental health diagnoses. The goal of this program is to integrate behavioral health services into primary care offices to offer assistance that supports the wellbeing of both the patient’s physical and mental health. Specifically, CoCM focuses on a defined patient population who are tracked in a registry to monitor treatment progression. The treatment plan focuses on measurement-based treatment to target, to ensure the patient’s goals and clinical outcomes are met. The CoCM team includes the primary care provider, the BHCM, and a psychiatric consultant to meet regularly for a caseload review where there are opportunities to adjust the plan of care for patients. The BHCM is the heart of the CoCM, facilitating communication amongst all team members and acting as the lead point of contact for the patients enrolled. This position is a great opportunity to be a valuable part of a multidisciplinary team within the primary care practices, and will be located within the population health office with the centralized care team. Knowledge, Skills and Experience Education Minimum of a Master’s Degree in Social Work from a school accredited by the council of Social Work Education. License / Certification / Registration Current LMSW licensure by the State of Michigan. LLMSW’s will be considered if licensure exam is passed and the candidate is within 6 months of completing their clinical supervision. Supervision can be provided for the duration of the supervision period. Experience Knowledge of Michigan’s Mental Health Codes Experience working in an ambulatory practice, preferred. Experience working with Epic, preferred. Skills & Abilities Knowledge of or experience working in a Collaborative Care Model (CoCM). Experience with medical and mental health social work. Experience consulting with psychiatric providers. Efficient, accurate assessment of patient needs and effective case dispositions. Skilled in developing rapport and effectively communicating with a diverse patient population. Proficiency with MS Word, Excel, Project, and Power Point. Demonstrates the ability to develop and maintain strong working relationships with colleagues at different levels of the business, up through the most senior levels within the enterprise. Ability to establish and maintain a high level of credibility with the patient and primary care team, to clearly articulate complex messages. Ability to create an open environment where conflicts as to methods and priorities can be aired and resolved in an objective manner. Excellent communication skills, with the ability to clearly communicate vision, mission, goals, themes, and key priorities that guide and focus the efforts of others. Able to coordinate and balance requirements between clinical outcomes and administrative activities Strong collaboration and influence capabilities. Exceptional organizational ability and the ability to achieve goals in the face of multiple pressures. Possesses flexibility to lead in an ever-changing work environment; ability to work with minimal direction and oversight; ability to deal with ambiguity and uncertainty. Superior prioritization, organizational, and management skills. Ability to work independently; resourceful and proactive. Clear and confident communicator internally and with members/external partners. Excellent problem-solving skills, particularly ability to react appropriately “in the moment”. Unyielding attention to detail. Essential Duties This job description is intended to cover the minimum essential duties assigned on a regular basis. Team members may be asked to perform additional duties as assigned by their leader. Leadership has the right to alter or modify the duties of the position. Supports the mental and physical healthcare of patients on an assigned patient caseload. While coordinating care with the patient’s medical provider and, when appropriate, other mental health providers. Screens and assesses patients for common mental health and substance abuse disorders. Facilitate patient engagement and follow-up care. Provides patient education about common mental health and substance abuse disorders and the available treatment options. Systematically track treatment responses and monitor patients (in person or by telephone) for changes in clinical symptoms and treatment side effects or complications. Supports psychotropic medication management as prescribed by medical providers, focusing on treatment adherence monitoring, side effects, and effectiveness of treatment. Provides brief behavioral interventions using evidence-based techniques such as behavioral activation, problem-solving treatment, motivational interviewing, or other treatments as appropriate. Provides or facilitates in-clinic or outside referrals to evidence-based psychosocial treatments (e.g. problem-solving treatment or behavioral activation) as clinically indicated. Participates in regularly scheduled (usually weekly) caseload consultation with the psychiatric consultant and communicates resulting treatment recommendations to the patient’s medical provider. Consultations will focus on patients new to the caseload and those who are not improving as expected under the current treatment plan. Case reviews may be conducted by telephone, video, or in person. Tracks patient follow-up and clinical outcomes using a registry. Documents in-person and telephone encounters in the registry and uses the system to identify and re-engage patients. Documents patient progress and treatment recommendations in Epic and other required systems to be shared with medical providers, the psychiatric consultants, and other treating providers. Facilitates 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. Facilitates referrals for clinically indicated services outside of the organization (e.g., social services such as housing assistance, vocational rehabilitation, mental health specialty care, substance abuse treatment). Develops and completes relapse prevention self-management plan with patients who have achieved their treatment goals and are soon to be discharged from the caseload. Demonstrates knowledge and maintains and respects patients’ right to privacy by following the HIPAA Privacy and Security policies and procedures. Role model behaviors that value the diversity of our team members, patients and customers and supports creating an environment that is inclusive, welcoming and respectful. Communicates with patients, families and customers using AIDET (Acknowledge, Introduce, Duration, Explanation, and Thank). Works in a safe manner and promptly reports any hazards identified in the work environment or related to assigned responsibilities. Adheres to policies and procedures designed to avoid, prevent and reduce the spread of communicable diseases. #J-18808-Ljbffr