Job Description

Steward Health Care Network (SHCN) takes pride in its community-based care model, which drives value-added tools and services to our communities, patients, physicians, and hospitals across the continuum of care. In addition, Steward Health Care Network promotes care coordination and collaboration within the network in order to provide high-quality, efficient care to patients. With Steward in the community, all residents can be sure that there is a world class doctor close to where they live.

The network is also responsible for the implementation and execution of our managed care contracts, medical management services, quality improvement programs, data analysis, and information services.

Position Purpose:

The Behavioral Health RN Case Manager is a core member of Steward's collaborative care team and will assist the Primary Care Physician and care team to ensure patients with severe mental illness and/or substance who experience ambulatory medical needs are met in the most efficient, cost- effective manner possible. The Behavioral Health RN Case Manager works closely with the patient's primary care provider and care management team to develop, implement and evaluate a plan of care tailored to the patient's unique needs. The Behavioral Health RN Case Manager provides consultation and assists members in understanding the implications and complexities of their current situation and/or overall medical care.

Essential Duties and Primary Accountabilities:

  • Provides telephonic medical consultation to patients with severe mental illness who have high rates of physical and behavioral health utilization
  • Ensures the appropriate delivery of services through Assessment and Case/Problem Identification, Coordination, Planning, Monitoring, and Evaluation.
  • Reviews comprehensive assessment and care plan completed by the assigned BH Care Manager/CHW and implements medical component in to care plan.
  • Assesses, plans, implements, monitors and evaluates options and services to meet complex behavioral health and psychosocial health needs of patients
  • Places referrals to external behavioral health and/or substance use community based resources to assist patient in accessing quality and cost effective care (i.e. - medication management, MAT treatment, etc.)
  • Coordinates care with internal and external resources to meet identified needs of the patient's care plan and collaborates with providers
  • Monitors and evaluates effectiveness of care plan and modifies plan as needed
  • Interacts continuously with members, family, physician(s), and other resources to determine appropriate behavioral action needed to address medical needs
  • Provides clinical consultation to physicians, professional staff and other teams members/supervisors to provide optimal quality patient care and effective operations
  • Identifies patients at high risk for long term/chronic care and collaborates with the Behavioral Health care team to develop and implement suitable life plans.
  • Develops criteria to identify ambulatory clients at risk for high cost/chronic care and intervenes to provide a care plan, which utilizes appropriate resources across the continuum.
  • Identifies availability of community services for clients who are in need of services that are not skilled.
  • Facilitates the delivery of services by establishing relationships with all health care providers, health plans, facilities, and community resources, ensuring appropriate utilization across the continuum of care.
  • Serves as the clinical conduit to the patients PCP and ensures patients are engaging with their PCP to complete their care management treatment plan or preventive care services
  • Performs Case Management services taking into consideration the client's physical, cultural, social, behavioral health and psychological needs.
  • Identifies need for and facilitates the development of ambulatory-based programs to effectively meet the needs of chronically ill and at-risk patients. Coordinates these efforts with SHCN Inpatient Case Management staff.
  • Supports SHCN efforts to meet federal and state regulations as well as health plan specific policies and procedures.
  • May perform utilization reviews per Interqual Guidelines.
  • Participates in committees and meetings at Steward Hospitals and IPAs.
  • Provides consultation and education to the client/family and other health care members as needed.
  • Participates in Case Management meetings and educational programs sponsored by SHCN Services, Steward Hospitals, and health plans.
  • Understands and adheres to all health plan and regulatory guidelines including NCQA/CMS/URAC/ERISA.
  • Maintains and respects patient confidentiality according to SHCN HIPAA policy and procedures.
  • Maintains documentation standards in conjunction with policy and procedures.
  • Provides concise and thorough documentation through psycho/social assessment and progress notes, including changes in medical psycho/social functioning, progression and attainment of goals, referrals to internal and external agencies, and contact/involvement with patient's family
  • Demonstrates cultural sensitivity and respect for the patient
  • Performs other functions as assigned

Education:

  • Bachelor's Degree in Nursing
  • Master's Degree, preferred
  • BLS Certified (CPR/First Aid)
  • Current RN License required

Years of Experience:

  • 3 plus years of acute medical/surgical experience and/or 3 plus years of Case Management experience.
  • Experience with patients with long term services and supports, preferred.

Work Related Experience:

  • Experience working with the needs of vulnerable populations who have chronic or complex bio-psychosocial needs
  • Experience working with disadvantaged populations, preferred
  • Experience in a managed care environment and case management experience, preferred
  • Experience working in a post-acute care environment, preferred
  • Possesses strong clinical background in long term services and supports (LTSS) with focus on the delivery of high quality and cost effective care, preferred
  • Knowledge of managed care principles and physician practice.
  • Knowledge of case management, utilization management, and referral management.
  • Demonstrates knowledge of managed care concepts for various health plan and capitated programs.
  • Collaborates with multiple providers to provide quality and cost effective care for risk members.
  • Must be able to effectively communicate, present and explain complex material with patients, family members, case managers, treating physicians and community organizations.
  • Must possess the interpersonal skills to engage individuals and families in helping relationships.
  • Must be able to cope with the pressure of time limitations while respecting the needs of the patient and the requirements of the organization/department.
  • Ability to take action in solving problems while exhibiting judgment and a realistic understanding of issues; able to use reason, even when dealing with emotional topics.
  • Ability to remain open-minded and change opinions on the basis of information, perform a wide variety of tasks and change focus quickly as demands change, and manage transitions effectively from task to task.
  • Must possess a strong belief in an organizational culture that encourages valuing and best service excellence practices demonstrated through personal behavior and work ethic.
  • Ability to work in several databases and to comply with established documentation requirements
  • Exceptional organizational skills; ability to multi-task and work independently and part of a team
  • Demonstrate ability to prioritize, multitask, and work in a rapidly changing environment with multiple demands
  • Maintains information in a confidential manner according to policy.

Specialized Knowledge:

  • Experience working with Behavioral Health/Substance Use population

Application Instructions

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