Care Facilitator; Behavioral Health

Join Optum

Optum is a global organization that delivers care, aided by technology, to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities.

Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.

This role supports coordinated, patient-centered care for at-risk individuals by facilitating care plans, monitoring adherence, and serving as a key liaison between primary care, behavioral health teams, and patients or their families. Responsibilities include assessing social, cultural, and health literacy factors affecting care; tracking appointments, referrals, tests, and medication compliance; and conducting outreach through phone. The position manages and analyzes data, prepares summary reports and presentations for clinicians, and ensures accurate documentation in the electronic medical record.

Schedule:

Monday - Friday, 8-hr shift between the business hours of 8:30am - 5pm; schedule will be determined by manager upon hire.

Location:

1250 Hancock St. Quincy, MA OR Wellesley, Beverly, Kenmore, Chelmsford, or Medford will be the primary home site depending on candidate's location.

Training will take place at Quincy site and/or other sites as arranged depending on candidate's location. This will be an office-based role, requiring work onsite one day per week, but is flexible based on need, and available space at site(s). May be requested to work at all of the above noted locations, depending on need.

If you reside in Quincy, MA, you will enjoy the flexibility of an office-based role as you take on some tough challenges.

• Facilitates the process of care for at risk patients, coordinates an accessible plan of care and tracks adherence
• Serves as a liaison between the primary care team, behavioral health clinicians and patient and/or patient's family
• Develops an understanding of patient's circumstances, health literacy, language and cultural beliefs or other social challenges impacting patient care or compliance and documents in medical record, as appropriate. Shares information learned with health care team
• Tracks patient adherence with scheduled appointments, labs, studies, referrals, and prescription compliance
• Serves as a resource in the collection and management of data, generation of reports, patient outreach and tracking of patient progress. Extracts and analyzes data; creates presentations to inform clinicians of analysis and summary reports
• Contacts patients via telephone calls, MyHealth and/or direct mailings. Guides patients through process of care including transitions, providing directions, identifying barriers and approaches, serving as advocate and facilitator. Supports communication with clinicians and validates patient understanding. Confers with primary care case manager or other resources to facilitate assistance for patient
• Ensures all necessary documentation is entered into patient's electronic medical record
• Assures that all medical records and documents are obtained from providers and schools in a timely fashion to have readily available for patient visits and roster reviews
• In collaboration with clinical team, identifies relevant patient education materials and community resources and distributes to patients
• Maintains a list of current community resources for frequently encountered issues. Confers with primary care social workers as needed
• Documents processes and standard work. Works with clinicians and management to identify opportunities to improve quality performance and implement recommended changes. Actively participates in care improvement activities
• Ability to assist with cross coverage
• Performs other duties as assigned
• Performs all job functions in compliance with applicable federal, state, local and company policies and procedures. Accesses only the minimum necessary protected health information (PHI) for the performance of job duties. Actively protects the confidentiality and privacy of all protected health information they access in all its forms (written, verbal, and electronic, etc.) taking reasonable precautions to prohibit unauthorized access. Complies with all Atrius Health and…