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Company: MedStar Health
Location: Rosedale, MD
Career Level: Mid-Senior Level
Industries: Not specified

Description

General Summary of Position
The primary responsibility of the Care Manager Community Based- HEART Team is to drive the delivery of the HEART Team service. The HEART Team Service is a holistic interdisciplinary community based medical and behavioral health service designed to help beneficiaries manage complex medical and behavioral health illnesses. It aims to restore health improve community daily living personal and social skills while reducing incidence of medical or behavioral health crises that lead to unnecessary use of the hospital system. The Care Manager Community Based-HEART Team is responsible for providing coordinating and supporting medical behavioral health and social need services as well as referral coordination. The Care Manager Community Based- HEART Team initiates implements and evaluates care plans and associated interventions that are culturally sensitive and developmentally appropriate. The Care Manager Community Based- HEART Team is also responsible for overseeing Community Health Workers assigned to the caseload.

Primary Duties and Responsibilities


  • Collaboratively develops care plans with HEART Team members and beneficiaries. Assists beneficiaries in identifying areas of strengths and needs to develop their own goals.
  • Documents beneficiary progress and treatment recommendations in medical record so they can be easily shared with primary care physicians psychiatrist and other treating providers.
  • Facilitates team meetings for HEART Team members beneficiaries and primary care providers.
  • Participates in regularly scheduled caseload consultation with the supervisor and/or HEART Team and communicates resulting treatment recommendations to the beneficiary and the beneficiary's care providers
  • Coordinates and monitors services including comprehensive tracking of activities in relation to care plan.
  • Designates the appropriate team staff so that specialized supports and/or clinical expertise is applied as clinically indicated for each beneficiary.
  • Provides brief interventions using evidence-based techniques such as Behavioral Activation Problem-Solving Treatment Motivational Interviewing or other techniques as appropriate.
  • Manages risk factors of patients/families (e.g. legal immigration status language barriers financial complications employment and disability)
  • Determines required level and frequency of services.
  • Provides supervision and guidance to assigned Community Health Workers/Advocates regarding service implementation.
  • Facilitates referrals for clinically indicated services outside the primary care clinic such as social services and housing assistance
  • In consultation with HEART Team facilitates treatment plan changes for beneficiaries who are not improving as expected.
  • Drives and travels to community locations various agencies and other outreach destinations.
  • Participates in 24/7/365 on-call rotation and coordinates after-hours resources in accordance with care plan and beneficiary need.
  • Provides services remotely in-office telephonically via telehealth in the community or beneficiary's home as beneficiary needs and preferences dictate.
  • Contributes to the achievement of established department goals and objectives and adheres to department policies procedures quality standards and safety standards. Complies with governmental and accreditation regulations.
  • Minimal Qualifications
    Education
    • Bachelor's degree in Social Work Psychology or Human Services required and
    • Master's degree in Social Work Psychology or Human Services preferred
    Experience
    • 3-4 years Experience working with patients who have co-occurring chronic medical and behavioral health conditions. Coordination and collaboration with multiple providers and agencies. Comprehensive care plan development. A superior communicator who shares information readily and concisely while remaining solution focused and collaborative in nature. required
    • One year of relevant professional-level work experience may be substituted for one year of required education.
    Licenses and Certifications
    • LCSW- License Clinical Social Worker Upon Hire preferred and
    • DL - Valid State Driver's License in good standing Upon Hire required and
    • CPR - Cardiac Pulmonary Resuscitation within 90 Days required
    Knowledge Skills and Abilities
    • Excellent oral communication writing organizational skills and abilities.
    • Utilizes approaches and strategies that support and optimize patient care outcomes that are based on the interdisciplinary plan of care.
    • Solution Focused
    • Collaborative nature and demonstrated ability to collaborate effectively in team settings.
    • Working knowledge of Microsoft Word Excel and PowerPoint applications.
    • Experience with Electronic Health Records

    This position has a hiring range of

    USD $59,820.00 - USD $101,836.00 /Yr.


     Apply on company website