Care Facilitator - Behavioral Health, Atrius Health

Overview

For those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. 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.

• 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
• Expected to be on site a minimum of once a week, that could be at any of the sites supported by the Quincy BH Hub

Required Qualifications:

• High School diploma or equivalency certificate (e.g. GED, HiSET, TASC Test) from an accredited institution or governmental unit
• 3+ years of experience in a clinical or social services setting
• Computer skills that include proficiency with electronic medical records (EMR), Microsoft Office - especially Word and Excel
• Knowledge and understanding of medical terminology
• Solid interpersonal and communication skills needed with the ability to interact effectively with patients and medical professionals

Preferred Qualifications:

• Experience in a Behavioral Health-related setting
• Ability to demonstrate a high level of cultural competence and sensitivity to patient needs and concerns
• Ability to engage patients in problem solving
• Sound judgment with the ability to work and make decisions in a fast-paced environment
• Excellent telephone skills, strong customer service and ability to build relationships with patients
• Ability to use all electronic tools and applications relevant to the performance of the duties of the position, including but not limited to phone, keyboard, computer and computer applications
• 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
• Complies with all Atrius Health and departmental privacy policies, procedures and protocols

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you ll find a far-reaching choice of benefits and incentives.

The hourly pay for this role will range from $20.38 to…