Position Overview:
The Behavioral Health in Primary Care at MIT Health, Care Coordinator, provides operational support for the activities and management of provider referral services for both mental health providers and community resources. The Care Coordinator identifies, coordinates and facilitates continuity of care including referrals to mental health treatment resources and other community resources (internal and external) that will assist the patient in complying with treatment plans. The coordinator manages and aligns activities, programs, and communications resulting in the proactive building and maintaining relationships within the Greater Boston Area mental health community.
Principal Duties and Responsibilities (Essential Functions):
- Prepare and present a daily report to Behavioral Health team clinicians, including prioritizing acuity when interfacing with patients either during initial triage interaction, during ongoing interactions, or other situations. Reports to the Behavioral Health clinical team members promptly to ensure patient receives prompt and appropriate
- Works with the Behavioral Health clinical providers to determine the needs of the patients. Encourages patient compliance, including needs-based assessment.
- Prioritizes acuity when interfacing with patients either during initial triage interaction, during ongoing interactions, or other situations. Reports to the Behavioral Health clinical team members promptly to ensure patient receives prompt and appropriate care. Coordinate with emergency facilities in the community should a patient need an emergent or urgent evaluation.
- Follows up with patients referred to outpatient providers to confirm whether a connection has been made.
- Assigns new patient to appropriate clinician so that patient needs align with clinical expertise, adjusting as needed to ensure proper balance of patient panel leveling.
- Communicates with other healthcare clinicians at MIT Health about patients’ care, needs, utilization, and follow up plans, e.g., ED Care Facilitators, inpatient Care Coordinators, post-acute case managers, social workers, pharmacists, etc.
- Using research database, refers patients to a variety of resources for follow up behavioral health care, psychopharmacology, therapy, coaching, neuropsychiatric testing, addiction services, PHP, IOP, and/or legal services, and other community resources.
- Ensure patients’ knowledge, understanding of plan, and compliance as it pertains to each’s treatment plan. Escalate to behavioral health provider and/or primary care provider when concern exists that patient is unable to comprehend instructions or is non-compliant.
- Ensures that appropriate community resources and support are offered to patients that will increase probability of patient compliance to treatment plans, improve continuum of care, and generally improve the patient experience and satisfaction. Follow up with patients to ensure follow up compliance with the community clinician they were referred to.
- Ensure that all information is always current and accurate and ensuring the integrity and confidentiality of all data and files. Conducts data mining in a timely and accurate manner as required to support individual patient, provider, or service level needs. Conducts quality control check on data, reports and resolve discrepancies internally.
- Researches and refers patients to a variety of resources for follow up Behavioral Health care, psychopharmacology, therapy, neuropsychiatric testing, addiction services, PHP, IOP, legal services and other community resources.
- Explain and clarify complex information to patients and providers to ensure comprehension by all parties, including clinical and health insurance parameters.
- Available to acts as a resource to in house clinicians for various patient needs and situations.
- Manages Ambulatory Safety Net [ASN] patients, following the parameters of the ASN grant. Collaborates, coordinates care and communicates with ASN staff in a timely manner.
- Manages and aligns activities, programs, communications events to ensure continuity of patient care when patient treatment plans require additional care from external therapy services as well as when patient care is transitioned from in house therapy to the utilization of external resources.
- Continually builds and maintains said external relationships to act as primary liaison with community and professional referral sources to meet patients' needs, with attention to adding therapy sources attuned to cultural diversity and underserved populations
- Provide input to the negotiation of vendor contracts and maintains relationships with vendors who provide offsite psychotherapy services.
- Creates and maintains a resource library/directory of diverse mental health provider and diverse community resources.
- Other duties as assigned
Minimum Qualifications:
- Bachelor’s degree in social work, counseling, psychology, human services, or a related field
- Minimum of five years’ experience in a human service field, administrative coordination of clinical services
Skills and Experience:
- Experience and ability to work as part of a cohesive interdisciplinary team
- Experience working with internal and external resources for patients and providers
- Proven ability to maintain confidentiality and use good judgment when dealing with patients
- Strong competency working with hospital computer systems and case management systems
- Competent using Microsoft word, PowerPoint, Smartsheet and excel
- Ability to work well with physicians and ambulatory staff in a practice or health center setting
- Demonstrates ability to present and speak in front of groups
Job number: 24541
Grade level: 8