Behavioral Health RN Care Manager

Position Title: Behavioral Health RN Care Manager Reports To: Director, Value Based Transformation FLSA Status: Exempt
Overview: The Behavioral Health RN Care Manager collaborates with health care providers to meet identified complex and episodic medical and social needs of the patient and to promote the efficient and cost-effective delivery of health services. The Behavioral Health RN Care Manager is responsible for providing developmentally appropriate mental health services/care management to patients within an integrated healthcare and wellness model also incorporating the disease management of patients with chronic conditions.

Essential Functions:

• Makes transition calls to discharged patients within the designated time frames and documents and tracks findings.
• Initiates or accepts referrals from staff for patient needs assessment, determines eligibility for resource assistance, and makes resource referrals.
• Provides follow up with individual patients, their families, and referral resources to ensure contact has occurred and patient needs have been met within limits.
• Establishes/maintains positive, ongoing working relationships with other community agencies, physician offices.
• Establishes and maintains effective network of community resources for cross-referral of patients.
• Develops and maintains a current resource directory for a wide range of support services.
• Provides current and appropriate general health and wellness education throughout interaction with patients as well as teaches self-management skills.
• Works closely with physicians, nurses and other medical staff to communicate a patient’s needs and concerns.
• Contacts patients for transition of care or follow up care, assesses their needs, identifies gaps in care, implements care plans if needed, notifies physician of findings.
• Utilizes effective interviewing techniques with strong limit setting abilities.
• Provides regularly scheduled collaborative care team meetings.
• Positive, flexible, and solution-focused attitude.
• Travel may be required to multiple office locations to meet with care team and patients.
• Effectively communicates with the disabled and elderly populations and general public, both in person and by phone.
• Communicates in a collaborative, effective manner with others and maintains good working relationships; able to establish rapport quickly with a wide range of people.
• Provides leadership for new or less experienced team members by training, developing, coaching, mentoring and being a positive role model.
• Assesses for potential barriers and provides resources or referrals as needed.
• Reviews hospital discharge information, assesses patient understanding, and provides education as needed. Follows up with patients to assure their needs are still being met after discharge.
• Provides referrals, education to patients upon their transition and in an outpatient setting.
• Identifies patients that may need care management services.
• Uses clinical judgment, critical thinking and problem-solving techniques when assessing patients in order to promote optimum patient outcomes and decrease potentially preventable ED visits or hospital admissions/readmissions.
• Provides ongoing care management for a diverse population of persons with chronic illnesses or disabilities of all types.
• Evaluates and develops care plans for care managed patients based on patient needs; collaborates with team as needed.
• Identifies and documents psychosocial needs; sends community referrals as needed and monitors for responses.
• Identifies gaps or barriers in self-management and provides education to assist as needed.
• Works with patients to close gaps in care; addresses barriers that may impact gap closure
• Coordinates patient services as needed.
• Uses oral and written communication to convey pertinent information to members of the health care team in a timely manner.
• Educates patients on disease processes, health maintenance, medication management and self-management skills.
• Encourages patients to make healthy lifestyle changes.
• Utilizes a positive proactive approach to function as a health advocate to engage patients.
• Interacts with the care team on challenging cases.
• Separates personal from professional interactions with patients and maintains professional/ethical boundaries.
• Follows “best practice”, policies, and procedures.
• Participates in continuous quality improvement to enhance care transition and care management of patients.
• Maintains required documentation for all care transition and care management activities.
• Maintains consumer con