Behavioral Health Care Coordinator

Behavioral Health Care Coordinator Valley Community Healthcare - North Hollywood, CA $28 an hour CORE JOB RESPONSIBILITIES (Essential Duties): Overview: Valley Community Healthcare is seeking a dedicated and compassionate BHS Care Coordinator to become an integral part of a comprehensive behavioral health service team. The ideal candidate will play a pivotal role in within an integrated system of care between primary care and mental health services, ensuring that patients seeking services are screened for mental health conditions such as anxiety, depression and substance use, and provide assistance in navigating the systems of care (internal and with community partners). BHS Care coordinator, assist in facilitating transitions of care, addressing care gaps, conducting high-risk patient follow-ups, coordinating referrals, screening for Social Determinants of Health (SDOH), and providing patient education for their care team panel. Utilizing Valley Community Healthcare’s (VCH) Patient Centered Medical Home protocols, the BHS care coordinator will engage with patients over the phone and in-person while working with clinic care teams to enhance patient centered care. This position requires strong communication skills, attention to detail, and a commitment to improving patient outcomes through comprehensive care coordination and reduction of mental health symptoms. The BHS care coordinator works as an integrated member of the BHS/VCH interdisciplinary clinic teams to communicate patient’s needs and care plans to the team members. The BHCM also helps patients navigate across the continuum of health care, including services received outside of VCH. Responsibilities: 1. Coordination of Care: Using various external sources (Lanes, PointClickCare, etc.) outreach to patients from the providers’ panel that have had a recent hospital or ED discharges related to mental health diagnosis. Facilitate smooth transitions between healthcare settings, ensuring continuity and coordination of care for patients moving between hospital, home, and other care environments. Collaborate with mental health care provider, healthcare providers, case managers, and other stakeholders to retrieve patient records and implement transition plans that prioritize patient seeing their mental health providers and primary care provider. Ensure that new patients and as appropriate, returning patients complete required screening tools. Assists with patient appointment reminders, missed appointment follow up and patient rescheduling Coordinates appointments with mental health care providers to ensure timely delivery of risk assessment, intake, diagnosis, treatment and wellness/maintenance follow up. Coordinates appointments with mental health care providers to ensure mental health provider’s time slots are utilized. Schedules patients in high acuity slots on a daily basis as needed. Attends and participates in meetings, committees, and training sessions as directed by Supervisor. Performs other duties as assigned by Supervisor. 2. Care Gap Outreach: Utilizing outreach lists developed by the QI data team, address mental health care and physical health caps that impacts patients mental and physical wellbeing. Follow established protocols and workflows to ensure patients care gaps are being addressed. Outreach should utilize various modalities of communication including texting, communication with the care team for ‘in reach’ and calling the patients for visits Work closely with mental health and healthcare providers to develop strategies for closing care gaps and improving overall patient care quality. 3. High-Risk Follow-ups: Perform brief consultation with patients with high PHQ9 score over 10 , or a score of 3 to question 9 on PHQ9, during their medical visit. Work closely with medical providers and care team to intervene with patients needing immediate consults due to danger to self, other, gravely disabled, high acuity related needs. Perform triage services, crisis intervention, case management, referrals and follow-up as required. Collaborate with the healthcare team to develop and implement personalized care plans for high-risk individuals. 4. Referrals Coordination: Manage the follow up of external referrals for the assigned providers’ panel, ensuring appropriate documentation and follow up with the patient. This could include but is not limited to… Follow up with patient for referral status and specialist visit information Following up with the specialist for records and ensuring provider reviews Updating referral information in the patient chart Utilize different modalities to communicate with the patient with updates to their referral status Participate in care team huddles and weekly clinical team meetings. Participate in clinical supervision meetings. Complete all required documentation by the end of each day Manage the department’s referrals by systematically enrolling and scheduling patients for mental health services, as designated by the payer source Monitors treatment adherence (including medication) Outreaches to patients who have missed mental health and psychiatric services. Collects and prepares reports and documentation as needed for planning and quality assurance as request by BHS director and Lead Clinician. Maintains confidentially and complies with HIPAA and compliance mandates at all times. Attends and participates in meetings, committees, and training sessions as directed by Supervisor. 5. Social Determinants of Health (SDOH) Screening and Follow-up: Conduct screenings to identify social determinants impacting patients' health and well-being for the providers’ panel. Work with mental health and medical provider to develop appropriate action plan for the patient and utilize partner resources to link patients to needed external services. 6. Patient Education: Provide education to patients and their families regarding the importance of mental healthcare screenings, participate in mental health related workshops / groups. Utilize educational materials in NG and resources to empower patients to actively participate in their mental healthcare journey. POSITION REQUIREMENTS: These specifications are general guidelines based on the minimum experience normally considered essential to the satisfactory performance of this job. Individual abilities may result in some deviation from these guidelines. Qualifications: Bachelor's degree in nursing, social work, healthcare administration, or a related field. Previous experience in care coordination, case management, or a related mental healthcare role. MA experience preferred. Knowledge of healthcare systems, transitions of care, and patient-centered care principles. Strong communication skills and the ability to collaborate effectively with multidisciplinary healthcare teams. Understanding of social determinants of health and their impact on patient outcomes. Proficiency in using electronic health records and other healthcare management software. Bi-lingual English/Spanish preferred. Oral Communication – speaks clearly and persuasively in positive or negative situations; listens and gets clarification; responds well to questions; demonstrates group presentation skills; participates in meetings. Position may require travel between different VCH facilities. These specifications are general guidelines based on the minimum experience normally considered essential to the satisfactory performance of this job. Individual abilities may result in some deviation from these guidelines. Job Type: Full-time Pay: $28.00 per hour Benefits: 401(k) matching Dental insurance Employee assistance program Health insurance Paid sick time Paid time off Vision insurance Ability to Relocate: North Hollywood, CA 91605: Relocate before starting work (Required) Work Location: In person