Work in Iowa Jobs

Employment Type:

Full time

Shift:

Day Shift

Description:

This is a remote position.

The Ambulatory Mental Health Team Lead functions as a working team leader devoting 25-30% of time providing care management and care coordination services to Population Health patients with mental health and substance use disorders residing in the community setting. This includes managing a panel of high-acuity mental health and/or substance use disorder patients, managing their transitions in care across the care continuum, and providing coaching and education to support patient self-management. Serves in an expanded health care role to collaborate with the patient’s primary care provider, specialists, other members of the health care team and patients/families to ensure the delivery of quality, efficient and cost-effective health care services. Assesses, plans, implements, coordinates, monitors and evaluates all options and services with the goal of optimizing the patient’s mental health. Integrates evidence-based clinical guidelines, preventive guidelines and protocols in the development of individualized care plans that are patient-centric, promoting quality and efficiency in the delivery of health care. Understands and complies with PHSO standard workflows, upholding accreditation level standards.

Under the direction of the PHSO Ambulatory Care Management Manager, the Ambulatory Mental Health Team Leader primarily functions as a mentor to Ambulatory Mental Health team members providing oversight and support in accordance with the PHSO’s policies and procedures. Responsible for coordinating the daily operational activities of the team. Works collaboratively with the Manager to identify process gaps, develop workflows and processes and ensure administrative and clinical processes are in place and working effectively to ensure staff is tracking to meet the department expectations. The lead secures and maintains the knowledge required to serve as a subject matter expert to the team. This individual represents the department in internal and external meetings as assigned by the Manager.

Essential Position Expectations:

Performs mental health and substance use disorder patient identification and risk stratification. Assists in routine patient outreaches for post-discharge follow up and/or ongoing mental health coaching support:

• Provides at least a monthly engagement conducted either by phone or virtually

• Completes routine assessments of physical, mental, social and functional needs

• Develops, implements and updates patient care plans

• Manages coordination and communication across providers, services, and markets

• Assess for adherence, barriers and gaps in recommended care

• Facilitates advance care planning discussions and the completion of advance directives for patients ≥ 18 years of age

• Manages transitions in care following hospital discharges, emergency department use and inpatient psychiatric and/or substance use treatment

Applies motivational interviewing to strengthen the patient’s own motivation for change and movement towards health behavior goals. Provides coaching and education to support self-management. Participates in quality improvement, measurement and data collection to include populations with clinical and financial risk. Provides ongoing ambulatory support for providers in managing CCM billing. Accepts direct referrals from care management team members and providers. Delegates to support team as appropriate. Informs primary care provider of ongoing care management activities, patient progress and changes in the patient’s health status. Documents all patient interactions in the patient’s health record or care management documentation system immediately after the call or meeting is completed. The maximum allowable time from interaction to documentation is one business day. Understands accountability for results and self-manages to support PHSO level success goals in the areas of quality, cost of care and patient experience. Upholds and supports PHSO standard workflows and procedures at accreditation level quality. Essential understanding of diverse substance use disorder treatment modalities.

Team Lead:

Under the direction of the Manager, develops, implements, and monitors administrative and clinical processes to ensure staff activities are focused on achieving PHSO program goals to improve quality of care, mitigate cost trends through supporting optimization of care delivery and improve member satisfaction for the mental health and substance use population. Coordinates assignment of daily work, ensures work completed within required timeframes and examines work product to ensure it meets departmental clinical and process guidelines. Provides feedback to staff on performance including identifying performance improvement opportunities and working collaboratively with staff to develop and implement remediation plans when appropriate. Works to ensure team output meets or exceeds regulatory, accreditation and customer requirements/expectations. Develops and manages remediation plans as necessary to address performance gaps and opportunity areas. Provides guidance to Manager on key opportunity areas and makes recommendations for workflow and program improvements. Provides leadership in related committees, task forces, and work groups with a focus on improved mental health outcomes for the populations served. Under direction of Manager and/or Regional Director, coordinate services with local and state FQHCs. Works to build working relationships and connections with community mental health and substance use treatment facilities, support services, providers, and resources.

Knowledge & Skills:

Ability to deal with confidential and sensitive information, requiring ongoing discretion and management of secure information. Strong communication (verbal/written) and organizational skills and ability to interact effectively with providers, clinic staff, and care management team members across the care continuum. Demonstrated capacity to problem solve and prioritize in complex situations. Demonstrates a wide theory base and sound clinical skills to function as a nurse generalist. Strong self-motivation and ability to work independently without direct supervision or support. Adaptability to performing a variety of duties, often changing from one task to another of a different nature without loss of efficiency or composure. Ability to function effectively in a team based environment. Basic Excel and Word skills. Ability to understand and apply guidelines, policies and procedures. Obtain Certificate of Competency in Population Health Care Management within 12 months of hire. Proof of completion of Mandatory Reporter within three months of hire. Proof of completion of Mental Health First Aid Certification within 12 months of hire.

Mental & Physical Demands:

Must be able to pass a pre-employment drug screening test at time of hire. Work with regular and predictable attendance. Maneuver within the physical work environment with some bending, stooping, reaching, and light lifting. Constantly able to use hands and fingers to type, write, and file. Frequently able to use near vision for viewing computer monitor and written materials. Occasionally required to detect unusual odors that could indicate environmental issues. Use of usual and customary equipment used to perform essential functions of the position.

Education: Graduate from an accredited school of nursing or social work. BSN or BSW preferred.

Experience: Minimum of 5 years previous nursing or social work experience or 3 years and BSN or BSW in lieu of experience. Mental health and/or substance use experience preferred.

Certifications & Licenses: RN applicants will require Iowa state licensure as a Registered Nurse and Basic Life Support required (BLS).

Our Commitment to Diversity and Inclusion

Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.

Our Commitment to Diversity and Inclusion

Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.

EOE including disability/veteran