Integrated Care Manager - Social Worker or Nurse
The Integrated Care Manager is responsible for identifying and coordinating appropriate services for Steward Health Choice Arizona (SHCA) members with complex or special service needs, including physical and behavioral health needs, in SHCA's Recover Wellness Integrated Care Management Program for members with Serious Mental Illness, and for members in other high risk populations. Responsibilities include: providing subject matter expertise and care management / care coordination to clinical teams identified as high risk, high cost, or who have specialized care needs including physical health needs.
Integrated Care Managers are responsible for overseeing and assisting clinical teams in:
- Effectively transitioning members from one level of care to another.
- Reducing hospital admissions and unnecessary emergency department and crisis service use.
- Providing clinical teams with the proper tools so members can self-manage care in order to safely live, work, and integrate into the community
- Identifying and transferring important clinical information and test results, such as discharge summaries, critical lab results, medications, emergency room visits, etc.
- Updating the team on changes in member status such as eligibility, court-ordered treatment guardianship, DNR, transition to adulthood, SMI, incarceration, pregnancy, out-of-state treatment, all cause hospitalizations, etc.
- Ensuring members are scheduled for prevention, EPSTD, disease management, and health promotion activities, consistent with need
- Analyzing predicted and actual outcomes and cost-effectiveness of a member's interventions / services based on best practices
- Developing, streamlining, monitoring, and adjusting members' Integrated Care Management Plans based on progress and outcomes to include:
- Clinical interventions recommended to the treatment team
- Strategies for successful transitions between levels of care / facilities / providers, discharge planning and coordination of care gaps
- Delineation of responsibilities for involved providers across systems for monitoring referrals and follow-up specialty care
- A schedule for routine health care services, medication monitoring, prevention, EPSDT, disease management, and health promotion activities
- Strategies, such as health coaching and wellness, to facilitate behavior change to address underlying health needs and member self-management
- A review of recent utilization information including inpatient admissions, emergency department visits, and prescription fills
- Care team information to facilitate coordination of care: active providers, their roles, and their contact information
- Participation in the design of integrated health activities and services; promoting SHCA integrated programs with network providers and stakeholders, as requested
- Participation in SHCA committees, projects, and work teams
- Developing relationships with treatment providers throughout Northern Arizona, including travel for site visits
- Performing other duties of similar nature and level as assigned
This position requires a Master's degree in a Behavioral Health Field (preferred: a current independent Arizona license in Social Work, Counseling, Marriage and Family Counseling, or Substance Abuse Counseling); or a current Arizona licensed Registered Nurse (RN) and a minimum of two years' experience; or an equivalent combination of education and experience sufficient to successfully perform the essential duties of this position
Knowledge of the Arizona Behavioral Health System and its resources
Knowledge of the AHCCCS Medicaid system
Knowledge of the principles and benefits of integrated health care and population health, and / or willingness to learn
Experience managing complex and unique caseloads for persons with both physical and behavioral health needs
Ability to document activities accurately and timely in an electronic medical record system
Ability to work effectively in a team model
Ability to clearly and effectively communicate, negotiate, and advocate both verbally and in writing
Valid Arizona drivers' license