The Project lead will collaborate multiple teams to deliver integrated, person-centered, and comprehensive care to eligible beneficiaries to successfully address the complexity of comorbid physical and behavioral health conditions. This position will help coordinate all care management team members to provide the following six core services: comprehensive care management, care coordination, health promotion, comprehensive transitional care, individual and family support, and referral to community and social support services. This position requires tracking and follow up, ensuring details of care are documented in the Electronic Health Record and population health management tool. Development of reports, data analysis, and follow up are necessary to meet and improve quality outcomes. Effective communication, organization, efficient time management skills, and the ability to successfully multi-task are essential to your success in this position.
- Perform lead coordination of the Behavioral Health Home program’s requirements, ensuring day-to-day functioning and coordination, including patient care referrals, program development and reporting, and administrative tasks as needed.
- Lead program staff in goal setting and implementation based on the project work plan and other identified program objectives. Monitor and evaluate the successful completion of those goals, and use outcomes to move the team forward.
- Develop and maintain required records, reports, and statistical data. This includes administrative tasks such as maintaining an active and inactive master caseload for patients within the program, completing monthly reporting, day sheets, progress notes, etc.
- Consult and collaborate with a multi-disciplinary team including primary care providers, behavioral health staff, substance abuse service providers, long term care, hospitals, other members of client care teams, partner services staff, and other HONOR COMMUNITY HEALTH staff involved in client/patient care. Regarding records, including admission/discharge.
- Participates in the selection of strategies to implement evidence-based wellness and prevention initiatives. Participates in initial care plan development including specific goals for all enrollees.
- Facilitates health education groups. Provides education on health conditions, treatment recommendation, medications, and strategies to implement care plan goals including both clinical and non-clinical needs.
- Monitors assessments and screenings to ensure findings are integrated in the care plan.
- Ensures Community Health Workers track referrals provided to patients/caregivers and documents outcomes within the Electronic Health Record.
- Reviews transitions of care reports provided through the Health Information Exchange and ensure team has appropriate tools to arrange for post-discharge follow-up.
- Train and assist team in process for coordinating and providing access to chronic disease management including self-management support and resources.
- Collaborates with team to implement wellness and prevention initiatives.
- Facilitates the use of the Electronic Health Record (EHR) and other Health Information Technology (HIT) to link services, facilitate communication among team members and provide feedback.
- Monitors, reports and analyzes performance measures and outcomes.
- Meets regularly with the care team to develop care plans and discuss cases and exchanges appropriate information with team members in an informal manner as part of the daily routine of the clinic.
- Assists with increased new patient and repeat care visits by promoting the center(s) within the community and connecting individuals to potential referral sources such as community based organizations, hospitals/urgent cares, and other groups and/or programs providing assistance to the under serviced patient population.
- Perform data collection and analytics relevant to patient outcomes.
- Effectively demonstrates superior interpersonal communication skills, developing and appropriate and professional rapport with patients, families, office staff, and external resources.
- Participate in organizational and programmatic quality improvement projects.
EDUCATION: Bachelor’s Degree in nursing preferred, Nursing Diploma or Associates Degree Required. State of Michigan license, certification and/or registration as a Nurse (RN) required. Certified nurse case manager preferred.
EXPERIENCE: A minimum of three years clinical nursing experience in a clinical, acute care or community setting required. Case management experience in a managed care setting strongly preferred. Coordination and oversight of an interdisciplinary team preferred.
COMPENSATION AND BENEFITS:
Honor Community Health offers competitive wages, Medical, Dental and Vision, 401k, and members of the NHSC.
Honor Community Health is an equal opportunity employer. We embrace diversity and encourage all applicants to apply.
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