The Mental Health Center of Denver
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LCSW/Care Coordinator - Green Vlly Rnch Med Ctr - Spanish pref.
at The Mental Health Center of Denver
Provide behavioral health consultation, brief assessment, prevention and interventions to adults, adolescents, children and their families within their medical home to improve psychosocial functioning. Accountable for assuring a high standard of quality and coordination of care, in support of Primary Care Clinic’s value based care (VBC) programs and CMS' CPC+ program BHC has a defined role, working in an advisory capacity to the Primary Care Clinic, creating and monitoring standards of care, and providing overall support of the VBC and CPC+ programs. Fluency in Spanish and English highly preferred.
LCSW $25.48/hr. - $30.55/hr.
Bilingual Spanish Differential - $2.50/hr
Provide behavioral health consultation, brief assessment, prevention and interventions to adults, adolescents, children and their families within their medical home to improve psychosocial functioning. Accountable for assuring a high standard of quality and coordination of care, in support of Primary Care Clinic’s value based care (VBC) programs and CMS' CPC+ program BHC has a defined role, working in an advisory capacity to the Primary Care Clinic, creating and monitoring standards of care, and providing overall support of the VBC and CPC+ programs.
- Evaluate crisis situations and apply appropriate interventions.
- Assist in the detection of "at risk" patients and development of plans to prevent further psychological or physical deteriorations.
- Provide assessment, consultation, and brief intervention for psychological/psychiatric problems and/or disorders.
- Teach patients, families and staff care, prevention and treatment enhancement techniques.
- Assist in the development of effective infrastructure to support the model of care developed.
- Provide diagnostic mental health assessments as well as individual, couple and/or group psychotherapy and crisis interventions to assigned clients (both children and adults).
- Facilitate the coordination of medication/medicinal needs of clients with psychiatric and medical resources.
- Support adults, children and their families using a variety of developmentally appropriate strategies (e.g. treating trauma across the lifespan).
- Collaborate with internal and external partners in support of the Individual/family’s growth and development.
- Maintain accurate and timely clinical documentation consistent with agency/primary care clinic standards.
- Lead or actively participate in meetings that support the Primary Care Clinic’s integrated health care model to provide comprehensive care for clients. Also, participate in team meetings, in-services and supervisory sessions as required.
- Identification, outreach and follow up in regard to patients that are high risk, have a gap score and gaps in care.
- Outreach to patients to ensure follow up visit with their PCP post inpatient or ER visit to the hospital.
- Complete the key interventions pertinent to patient care and follow up needs.
- Collaborate with the payer systems and payer Care Coordinators on specific patient care needs.
- Provide patient education relative to the patient’s diagnosis and treatment plan.
- Outreach to patients to encourage them to work with their applicable payer Case Manager, Disease Manager or Wellness Program designee.
- Meet with payers in joint governance and other VBC and CPC+ meetings.
- Review reports from payers and assist Director of Quality in the interpretation of the reports and actions needed
- Obtains and analyzes quality metrics and reports for care opportunities, supports practice implementation of care coordination and care management, identifies action plans for providers to implement to improve cost, quality and the patient experience and participates in design, development and implementation of community learning forums.
- Test and pilot new VBC/CPC+ initiatives and work with leadership on refining processes, helping HOPP achieve contractual metrics.
- Work with management on communication to physicians regarding available patient care programs through the VBC/CPC+ programs- both written/email communication and visits to provider meetings as necessary.
- Conduct practice needs assessment to learn more about practice demographics, their daily operations and current workflows.
- Collaborates with Primary Care Team to meet provider and practice needs.
- Supports the efforts of providers and practice teams on office based care delivery interventions resulting in cost of care savings and improved health outcomes for patients.
- Provides education for practices to develop expertise with metrics and data review for quality improvement.
- Shadow and/or train physicians and medical staff as necessary in clinical workflows and coordination of care to improve clinical quality and achieve VBC/CPC+ goals.
- Assist in the development, implementation and monitoring of corporate and/or policies and procedures as they relate to VBC/CPC+ programs.
- When the need arises, will perform other duties as assigned by supervisor.
- Maintain a trauma informed environment of wellbeing.
- Other duties as assigned.