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Responsibilities will include:

• Quarterbacking our integrated behavioral health service which closely aligns with the evidence-based Collaborative Care Model, for all patients with mild/moderate behavioral health needs including substance use disorder. Duties include but are not limited to: outreaching and engaging qualified patients, accepting (and at times initiating) warm handoffs from other team members, completing initial intakes to understand patient risks and needs, delivering brief therapeutic interventions and short-term therapy, and referring and navigating to community resources for access to the broader behavioral health continuum of care.
• For members with complex serious mental illness and/or substance use disorder, collaborating with psychiatrists, RNs, and community health workers to perform community-based outreach and engagement, initial intakes, short-term therapy and referral and coordination with community resources for access to the broader behavioral health continuum of care.
• Assisting the clinical team in urgent triage for behavioral health related issues
• Supporting patients in transitions of care from facilities for admissions related to behavioral health diagnoses, including but not limited to: coordinating on discharge plans with inpatient care management, performing assessments to identify risk factors for readmissions, ensuring close follow-up and coordinating services.
• Caring for patients primarily virtually via video, telephone, or text but also in the home and community as needed.
• Establishing and fostering trusting relationships with patients and ensuring care is aligned with the patient’s goals and values.
• Participating in multi-disciplinary case conferences and clinical rounds to ensure holistic and appropriate care for patients.
• Providing formal and informal coaching and education to other clinical and non-clinical team members about supporting patients with behavioral health issues.
• Collaborating with external providers and community-based organizations to advocate for patient care aligned with their goals.
• Providing feedback on program design and workflows to ensure we are providing the best patient care possible.
• Ensuring timely and appropriate documentation.
• Roles and responsibilities may evolve as our care model develops.

What makes you a fit for the team:

• Passionate about caring for complex, historically underserved patients with co-occurring chronic and behavioral health conditions in an integrated, multi-disciplinary model anchored in home-based and tech-enabled virtual care.
• Committed to providing the highest quality, outstanding clinical care to all patients, regardless of their needs.
• Consistently go the extra mile to ensure that our patients have the best healthcare experience possible.
• Excited to be a part of and contribute to the development of a rapidly evolving, innovative care model.
• Enjoys continuously learning and adapting workflows to improve patient care.
• Excellent communicator able to coach and mentor clinical and non-clinical members of multidisciplinary teams on excellent patient care.

Desired skills and experience:

• Required
• LCSW or LSW or LPC with an active license in the state of Michigan, Colorado or Massachusetts.
• 3+ years of experience in assessing, planning, and managing behavioral patient care as acquired through direct clinical experience, including direct therapy and care/case management work.
• Experience and comfort working within an interdisciplinary care team, and specifically working alongside community health workers and patient navigator team members.
• Advanced communication and interpersonal skills with all levels of internal and external customers.
• Comfort with electronic medical record documentation and excited about how technology can support your work and drive ongoing improvement towards new and better care.
• Valid unrestricted driver's license and access to an insured vehicle for daily use.

• 
  Preferred
• 2+ years in care/case management role preferably in an ambulatory care or community service provider managing high risk populations with serious mental illness and substance use disorder.
• Experience in transitions of care management for patients discharging from behavioral health facilities or step-down units, including performing detailed medication reconciliation, patient education, and connection/navigation to appropriate services.
• Experience as an active participant in continuous quality improvement projects.
• Extensive knowledge of Medicare and Medicaid, state benefits and community resources for behavioral health needs in the local market.
• Proven experience in developing and sustaining internal and external client relationships with healthcare professionals, including community service providers.
• Highly skilled in trauma-informed care and culturally sensitive care.