Aya Healthcare
Behavioral Health Care Management Services
Responsible for the delivery of behavioral health care management services in the ambulatory primary care practice setting to a variety of patient populations across the lifespan. Coordinates care to ensure patient/family have access to community services. Administers behavioral health screenings and conducts and arranges for more detailed assessments when indicated. Integrates evidence-based guidelines in the development of individualized patient centered care plans with the patient/family. Monitors/evaluates progress with the goal of optimizing the patients health status. Delivers brief interventions to support necessary lifestyle and behavioral changes. Responds to crisis situations in the ambulatory setting. Identifies high-risk psychosocial needs of patients/families. Collaborates with patients families and the interdisciplinary care team to ensure understanding of the impact the disease or illness has on the patient's mental and emotional health. Offers a range of brief solution-focused prevention treatment and recovery services for patients with mild to moderate risk factors. Collaborates and works effectively as part of the interdisciplinary health care team to ensure delivery of quality efficient and cost-effective team-based health care services. Provides culturally competent clinical services which are relevant to patients/families. Emphasis of duties may vary depending upon the area of assignment. Masters of Social Work degree with one-year recent medical or mental health experience preferred.Licensed Masters of Social Work (LMSW) Preferred.Limited License Master of Social Work (LLMSW) Considered.Ability to use word processing spreadsheets presentation programs and other software relevant to the job.Demonstrates customer focused interpersonal skills to interact in an effective manner with practitioners the interdisciplinary health care team community agencies patients and families with diverse opinions values and religious and cultural ideals.Demonstrates ability to work autonomously and be directly accountable for practice.Demonstrates leader qualities including time management verbal and written communication skills listening skills problem solving critical thinking analysis skills and decision-making priority setting work delegation and work organization.Demonstrates ability to develop positive ongoing relationships and set appropriate boundaries with others.Ability to affect change work as a productive and effective team member and adapt to changing needs/priorities.Ability to manage complex clinical issues utilizing assessment skills and protocols.Assume responsibility for professional development.Attend assigned training and meetings.Develop and support a positive work climate and the overall team effort of the department.Participates in the development and revisions of departmental processes and standard work.Flexibility to adapt to the needs of the department.Function autonomously on behalf of the providers under the Bronson system and in collaboration with the providers for all identified responsibilities.Identify appropriate patients to work with.Assess patient needs coordinates services and referrals.Assess the nature of the crisis and the immediate social/emotional needs and strengths of the patient and family in order to provide appropriate intervention.Perform appropriate screenings based on patient population and need.Identify problems surrounding the crisis situation and may act as patient advocate to improve such problems.Collaborate with other members of the patient care team to understand each situation recommends or provides immediate treatment and solution focused interventions.Work effectively as part of the interdisciplinary healthcare team collaborating and communicating regularly with the PCP patient health care team and other members across the care continuum and community.Develop a comprehensive individualized plan of care with targeted interventions for patients.Conduct regular follow-ups with patients to evaluate progress and response to plan of care promote continuity of care and ensure improved health outcomes.Evaluate effectiveness of interventions continuously and modify the plan of care as needed.Provide patient self-management support with a focus on empowering the patient/family to build capacity for self-care.Provide education to patients of all ages based on knowledge of growth/development across the lifespan.Promote healthy behaviors in all populations and ensure navigation assistance with community resources.Link patients to social services programs and make referrals to community agencies and other healthcare specialist to resolve emotional social or financial problems impacting health care status. Ensure the appropriate follow-up treatment and support is available.Implement clinical interventions and protocols based on risk stratification and evidence-based clinical guidelines.Thoroughly document each case into the patient's medical record such as care coordination care management and behavioral health activities as appropriate.Identify and provides for learning needs of patients families and healthcare coworkers.Work with ambulatory care management managed care and practice leadership to continuously evaluate processes identify problems and propose/develop process improvement strategies to enhance patient care and ensure program & metrics are met.Mentor and supervise students as needed/able.
Responsible for the delivery of behavioral health care management services in the ambulatory primary care practice setting to a variety of patient populations across the lifespan. Coordinates care to ensure patient/family have access to community services. Administers behavioral health screenings and conducts and arranges for more detailed assessments when indicated. Integrates evidence-based guidelines in the development of individualized patient centered care plans with the patient/family. Monitors/evaluates progress with the goal of optimizing the patients health status. Delivers brief interventions to support necessary lifestyle and behavioral changes. Responds to crisis situations in the ambulatory setting. Identifies high-risk psychosocial needs of patients/families. Collaborates with patients families and the interdisciplinary care team to ensure understanding of the impact the disease or illness has on the patient's mental and emotional health. Offers a range of brief solution-focused prevention treatment and recovery services for patients with mild to moderate risk factors. Collaborates and works effectively as part of the interdisciplinary health care team to ensure delivery of quality efficient and cost-effective team-based health care services. Provides culturally competent clinical services which are relevant to patients/families. Emphasis of duties may vary depending upon the area of assignment. Masters of Social Work degree with one-year recent medical or mental health experience preferred.Licensed Masters of Social Work (LMSW) Preferred.Limited License Master of Social Work (LLMSW) Considered.Ability to use word processing spreadsheets presentation programs and other software relevant to the job.Demonstrates customer focused interpersonal skills to interact in an effective manner with practitioners the interdisciplinary health care team community agencies patients and families with diverse opinions values and religious and cultural ideals.Demonstrates ability to work autonomously and be directly accountable for practice.Demonstrates leader qualities including time management verbal and written communication skills listening skills problem solving critical thinking analysis skills and decision-making priority setting work delegation and work organization.Demonstrates ability to develop positive ongoing relationships and set appropriate boundaries with others.Ability to affect change work as a productive and effective team member and adapt to changing needs/priorities.Ability to manage complex clinical issues utilizing assessment skills and protocols.Assume responsibility for professional development.Attend assigned training and meetings.Develop and support a positive work climate and the overall team effort of the department.Participates in the development and revisions of departmental processes and standard work.Flexibility to adapt to the needs of the department.Function autonomously on behalf of the providers under the Bronson system and in collaboration with the providers for all identified responsibilities.Identify appropriate patients to work with.Assess patient needs coordinates services and referrals.Assess the nature of the crisis and the immediate social/emotional needs and strengths of the patient and family in order to provide appropriate intervention.Perform appropriate screenings based on patient population and need.Identify problems surrounding the crisis situation and may act as patient advocate to improve such problems.Collaborate with other members of the patient care team to understand each situation recommends or provides immediate treatment and solution focused interventions.Work effectively as part of the interdisciplinary healthcare team collaborating and communicating regularly with the PCP patient health care team and other members across the care continuum and community.Develop a comprehensive individualized plan of care with targeted interventions for patients.Conduct regular follow-ups with patients to evaluate progress and response to plan of care promote continuity of care and ensure improved health outcomes.Evaluate effectiveness of interventions continuously and modify the plan of care as needed.Provide patient self-management support with a focus on empowering the patient/family to build capacity for self-care.Provide education to patients of all ages based on knowledge of growth/development across the lifespan.Promote healthy behaviors in all populations and ensure navigation assistance with community resources.Link patients to social services programs and make referrals to community agencies and other healthcare specialist to resolve emotional social or financial problems impacting health care status. Ensure the appropriate follow-up treatment and support is available.Implement clinical interventions and protocols based on risk stratification and evidence-based clinical guidelines.Thoroughly document each case into the patient's medical record such as care coordination care management and behavioral health activities as appropriate.Identify and provides for learning needs of patients families and healthcare coworkers.Work with ambulatory care management managed care and practice leadership to continuously evaluate processes identify problems and propose/develop process improvement strategies to enhance patient care and ensure program & metrics are met.Mentor and supervise students as needed/able.