Direct Service:

• Provides behavioral health screenings at assigned PCP clinics,
• Provides psychosocial support and education to patients during warm hand-offs and follow up contacts
• Provide patient education resources about common mental health and substance abuse disorders and the available treatment options as assigned by BH clinician and consulting psychiatrist.
• Provides telephone screening as appropriate,
• Assists patient upon arrival for virtual BH session,
• Assists patient with login and follow up to available cognitive behavioral health modules
• Referral and linkage service to specialty care and community based social services.
•  Conduct patient contacts over the phone or in person/in patient's home to record patient's current status, ability to follow care plan, barriers to care and alert care manager of issues/concerns within department guidelines.
• Effectively uses patient engagement strategies to reach and enroll patients, assist patients in self-actualization in their healthcare needs.

Coordination of care:

• Effectively and efficiently communicates with patients and healthcare professionals to ensure smooth care transitions.
• Support the mental and physical health care of patients on an assigned patient caseload.
• Closely coordinate care with the patient’s medical provider and, when appropriate, other mental health providers.
•  Communicate regularly with assigned OPCM to ensure coordination of care
•  Reviews, retrieves tasks/messages for IDT within physician practice EMR.
• Alert care manager and BH clinician of issues/concerns
•  Identifies and maintains appropriate communication with supervisor involving problems and observations in course of daily operations
•  Communication with case managers, managers, directors, other health care professionals, and various staff in a positive fashion in order to promote behaviors of excellence, patient satisfaction, quality services delivered and resolution of issues
• Participate in regularly scheduled (usually weekly) caseload consultation with the psychiatric consultant and communicate 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.
•  Facilitate 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).

Recordkeeping:

• Maintains behavioral health screenings within established guidelines
• Ensures appropriate releases are signed and up to date per policy
• Maintains record of patients being seen by BH clinician
• Preparation and scheduling of the weekly BH IDT’s
• Ensures BH specialty care referrals are made and followed up
• Utilizes department EMR to document all activities and outcomes within department guidelines

Education/Experience Required:

• Bachelor's degree and 4-5 years experience working with behavioral health patients in a hospital or clinic setting

Knowledge, Skills & Abilities Required:

• Good communication skills. Ability to work as a team member. Competent computer keyboard, laptop maneuvering, competent in Windows, Excel, database entry. Good organizational skills. Ability to handle difficult calls and maintain professional conduct. Willingness to be flexible with job responsibilities

Physical Requirements and Working Conditions:

• Knowledge of motivational interviewing skills
• Knowledge of behavioral health disorders
• Ability to work under stressful conditions.
• Ability to effectively communicate with physicians
• Excellent phone mannerisms, ability to effectively engage conversation, motivate and engage patients to participate in our program, and speak to all types of patients, particularly seniors.
• Ability to work in changing environment.
• Ability to prioritize independently and respond to multiple simultaneous requests.
• May need some regional travel required between clinics and for meetings
• Ability to lift up to 35 pounds without assistance. For patient lifts of over 35 pounds, or when patient is unable to assist with the lift, patient handling equipment is expected to be used, with at least one other associate, when available. Unique patient lifting/movement situations will be assessed on a case-by-case basis.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.