The Population Health Care Manager evaluates patients' behavioral health and substance use care needs and promotes quality outcomes and treatment via a variety of modalities and engagement strategies. The Population Health Care Manager works directly with patients in the ED, inpatient and outpatient settings and telephonically to support patients' unique care needs. They work directly with hospital clinicians and care management team members (which may include RN's, Social Workers, MDs, and Coordinators) to address patient needs across the continuum of care as well as provide education and consultation to members, family/caregivers, and other parties involved in the member's care. The Care Manager also makes community-based field visits.
- Applies care management principles by advocating, informing, and educating patients with substance use and/or mental illness diagnoses on services, self-management techniques, and health benefits related to the continuum of care.
- Reviews discharge planning, assessments, medical records, and screening for patients currently admitted to the ED, inpatient, or receiving care in Ambulatory Care.
- Develops care plans that align with the physician's treatment plans and recommends interventions that align with proposed goals.
- Completes social determinant of health assessments to identify barriers and opportunities for intervention.
- Generates referrals to providers, community-based resources, and appropriate services and other resources to assist in goal achievement and maintenance of successful health outcomes.
- Liaise between service providers such as doctors, social workers, discharge planners, and community-based providers to ensure care is coordinated and care needs are adequately addressed.
- Utilize Epic and the Pathfinder Compass Rose program to identify and engage ED patients with substance abuse issues and coordinate appropriate transitions of care.
- Serve as a liaison between the hospital, community-based SUD treatment providers, and other relevant organizations to ensure a smooth and effective transition of care.
- Educate patients and families on SUD-related issues, treatment options, and the importance of continuing care post-discharge.
- Maintain detailed records of patient interactions, interventions, and outcomes, ensuring compliance with confidentiality regulations and hospital policies.
- Use the LOCADTR 3.0 tool for precise referrals of individuals with SUD to optimal treatment settings.
- Provides direction, support, and supervision to assigned Certified Recovery Peer Advocate (CRPA) team members.
A. Education-Master's degree in Mental Health or Social Work B. Licenses - Current license in Mental Health or Social Work (LMHC, LMSW). C. Experience/Skills Required: • Minimum of 2 years of experience working with individuals with substance use disorders, preferably in a hospital setting. • Demonstrated ability to manage large caseloads and effectively work in a fast-paced environment • Proficient with simultaneously navigating the Internet and multi-tasking with multiple electronic documentation systems • Experience using Microsoft Excel with the ability to edit, search, sort/filter and other Microsoft and EMR systems. • Work experience requiring effective communication and engagement skills, as well as healthy boundary-setting. D. Experience/Skills Preferred: • Bilingual in English and Spanish preferred.