Behavioral Health Coordinator
Full-time
Full Time
Hourly
SCHS is a 90-100 employee, full-service, non-profit healthcare clinic serving the needs of the South Minneapolis community. Come make a difference in the lives of people every day while helping us achieve our mission: To improve the health of our patients and communities by delivering exceptional care, removing barriers, and promoting healthy lifestyles.
ROLE:
This individual serves as the central facilitator to patients assigned to their care. Their general function is to guide and coordinate care and collaborate with primary care providers, RNs, MAs, and clinic staff in identifying needs, organizing activities, and organizing plans of care for patients with behavioral health conditions. They are an advocate for the patient and work to link them with health and community resources that provide a range of services, promote self-management, improve health, and reduce disparity. They assist patients to achieve health goals and improve health care outcomes.
JOB DUTIES:
Serve as a key point of contact for discussing and enrolling patients into the SCHS behavioral health program (document the patient’s acceptance or denial).
Work directly with patients and their primary care provider(s) and other clinic team members to build and maintain the patient care plans.
Manage depression/anxiety measures and follow ups (in clinic or by phone) in accordance with Minnesota quality standards.
Build relationships with patients, patient’s families, guardians, etc.
Introduce patients to the wide variety of services available across the organization as well as
identifying outside resources and services as necessary.
Serve as an advocate for the patient in understanding needs surrounding shelter, child care,
transportation, safety and other social determinants of health.
Conduct basic screenings of patients within primary care, including review of barriers to health self-management, depression, stress and substance use.
Provide health education and coaching to patients and refer patients to other care team members (nurses, patient advocates, primary care provider, outside specialists, etc.) as necessary. Topics discussed may include but are not limited to:
o Medication knowledge, adherence and accessibility
o Benefits of best practice treatment for their chronic conditions
o Encourage the patient to identify and set specific health goals in conjunction with goals set by their care provider(s).
Carry out structured clinical protocols with patients in person or by telephone.
Intervene appropriately in crisis prevention and de-escalation.
Serve as a bridge between the patient and internal and external referrals. May work directly with the referral specialist to connect the patient to external community agencies and referral sources when indicated by the care team.
Maintain and document regular communications with patients in the electronic health record.
Manage and work inpatient and emergency room tracking and facilitate appropriate follow ups as needed.
Manage tracking spreadsheet for reporting and follow up.
Contact enrolled patients on a monthly basis. Make additional inquiries/contacts as needed or
requested by the patient and/or their care team.
Work collaboratively with clinic staff to implement and refine workflows throughout the clinic
with goals to improve patient satisfaction and care.
Continuously seek, build and maintain relationships with community partners and resources.
Determine if patient has existing insurance coverage; discuss payment options and schedule appointment with patient advocate, if necessary.
Manage wait list on Epic and follow up.
Ensure patient exam rooms are fully restocked with BH business cards, DV resources, child development resources, post-partum education and self-harm resources.
Prepare for next day visits through pre-visit planning process to verify if service plans or forms such as PHQ, SDQ, CASII and ECSII need to be updated.
Enter completed paper work into MN-ITS and ensure paper work is scanned into patients chart.
Create binders with DV resources for patients and other clinic team members update and refill them when necessary.
Assist with other duties and responsibilities as assigned.
KNOWLEDGE, SKILLS, AND ABILITIES:
Attend and participate in staff meetings and committees.
Assist with resolving episode of care for mental health due to non-attendance.
Schedule behavioral health visits according to the established schedule for each provider.
Confidence, professional judgment, and grace under pressure.
Works well both independently and as part of a team.
Exceptional verbal and written communication skills.
Flexibility--nimble in response to an evolving workload.
Exhibit good rapport with clients of varying ethnic backgrounds and socio-economic status.
Able to use office equipment such as computer, phone, fax, telephone, etc.
Excellent time management and organizational skills; attention to detail.
Commitment to the SCHS mission and staff values.
MINIMUM QUALIFICATIONS:
Previous experience in and environment that provides direct patient care, case management, and/or patient education.
Associates degree in human services or a Community Health Worker certificate.
Familiar with medical and pharmacological terminology.
Experience working with various Microsoft Office applications—Word, Excel, Outlook, etc.
Bilingual (English/Spanish) strongly preferred.
To apply:
Send resume to meierdingm@southsidechs.org
RN/Care Coordinator
Full-time
Full Time
$30-38/hour
https://neighborhoodhealthsource.org/
ESSENTIAL FUNCTIONS & RESPONSIBILITIES:
General Nursing
• Serves as the contact point, advocate, and informational resource for patients, care team,
family/caregiver(s), payers, and community resources
• Handles incoming triage calls:
o Provides appropriate patient education regarding medical condition
o Provides medication instructions
o Supports providers by following up with patients regarding their lab/imaging results as guided
by the provider
o Documents telephone discussions in the patient’s electronic medical record (EMR)
• Handles incoming Nursing Home Orders
• Handles incoming pharmacy questions, clarifications and prior authorizations
• Calls patients with medication changes, directions and education, as ordered by providers
• Provides nursing support, when needed, to the Nurse Midwives and NHS providers
• Utilizes the Patient Portal to communicate with patients
• Sees patients on daily nurse schedule:
o Responds to the needs of walk-in patients
o Assists providers as needed
o Provides education on medical condition, e.g., asthma, diabetes, family planning
o Reads and documents PPD results
• Provides refill requests that come through the EMR, phone or fax
• Reconciles medications
• Maintains a logbook of all dispensed medication at the direction of the medical provider
• Maintains an emergency box of medications
• Oversees the application/enrollment and tracking process for patients in indigent medication
programs
• Prescribes medications per standing order protocols, e.g., STI treatment, Vitamin D deficiency
• Provides community-based nursing care as established by the organization, as requested
Care Coordination/Case Management Support
• Maintains Health Care Home (HCH) and FUHN registries for patient follow-up:
o Assists with the identification of “high risk” patients (those with chronic illness and/or special
health care needs)
o Contacts patients to enroll them into HCH and documents patient’s acceptance or declination,
to populate the registry
o Contacts patients that are on the FUHN ID/ Stratification tool to get them in for follow-up care
and educates patients on when to utilize the ER
o Reviews FUHN/ID Stratification patient’s EMR to see what patients may need; refers to
specialty providers and to helps with medication reconciliation
• Works with patients to plan and monitor care:
o Assesses patient’s unmet health and social needs
o Develops a care plan with the patient, family/caregiver(s) and providers (emergency plan,
health management plan, medical summary, and ongoing action plan, as appropriate)
o Monitors adherence to care plans, evaluates effectiveness, monitors patient progress in a
timely manner, and facilitates changes as needed
o Creates ongoing processes for patient and family/caregiver(s) to determine and request the
level of care coordination support they desire
• Facilitates patient access to appropriate medical and specialty providers
• Educates patient and family/caregiver(s) about relevant community resources
• Cultivates and supports primary care and specialty provider co-management with timely
communication, inquiry, follow-up, and integration of information into the care plan regarding
transitions in care and referrals
• Facilitates and attends HCH meetings between patient, family/caregiver(s) and provider
• In collaboration with the primary care provider, assigns the appropriate tiering level based on
required criteria for HCH patients
• Advocates for the participant in understanding needs surrounding transportation, shelter, child
care and safety. Refers participant to behavioral health services if warranted
• Keeps EMR care plans updated for easy access by HCH Team
• Interacts, communicates and collaborates with HCH Team daily in-person, by phone, inbox
messaging and/or team huddles to update and advance care coordination within the Team
• Utilizes all available tools to deliver education, instruction, care coordination and training,
including: computer; patient registry; HCH brochure; HCH care plan; other HCH policies &
procedures (tiering process, pre-visit planning, screening process); after-visit summaries; disease
management brochures; disease management participant tracking records (Diabetes glucose
records, nutritional records, wellness/exercise plan, blood pressure record); disease-specific
educational handouts; services offered by NHS
CORE REQUIREMENTS:
• Works collaboratively and respectfully with staff and others—individually and as part of a team—
to achieve optimal efficiency, outcomes and morale
• Interacts in a culturally competent manner with individuals and groups from diverse backgrounds,
including but not limited to: socio-economics, race and ethnicity, nationality and religion, both inclinic and in the community
• Maintains excellent and punctual attendance
• Attends and actively participates in staff and departmental meetings
• Attends agency functions and meetings as relevant or required
• Works at any or all NHS clinics, as needed
• Uses computer daily including e-mail, word documents, spreadsheets, patient management
system, electronic health record, and patient portal, as needed to carry out essential job functions
• Maintains any required licensure/certification
• Demonstrates commitment to agency mission and goals
• Abides by corporate compliance program, HIPAA regulations and other agency policies and
procedures
• Participates daily in pre-visit planning and huddles (RN, Provider, Medical Assistant, Front Desk)
• Plans, organizes, and multitasks
• Speaks, understands, reads and writes English sufficiently to carry out all essential duties
• Performs other duties as assigned
QUALIFICATIONS
• Graduation from an accredited nursing program
• Current Minnesota RN license
• Minimum one year experience in a primary care setting preferred
• Patient education experience
• Family planning experience highly desired
• Motivated to improve the health of the community
• Excellent interpersonal communication
Cancer Care Coordinator
Full-time
Full Time
Hourly
ROLE: This individual is responsible for identifying patients in need of cancer screening and
facilitating the outreach, education, and scheduling of said patients.
JOB DUTIES:
Review clinical quality measure lists for cancer screening provided by Director of Quality to
identify patients in need of cancer screening, complete patient outreach and education for
necessary cancer screenings via bulk text messaging and phone calls.
Provide education and schedule patients for appropriate appointments that can address their
preventative health care needs including cancer screening.
Manage and monitor Minnesota Health Department (MDH) SAGE and SAGE SCOPES programs
clinic wide; ensure paperwork is completed properly and sent to SAGE Program for claims
processing no less than on a weekly basis.
Work in collaboration with SCHS and MDH Billing department to manage any issues that may
arise in regard to SAGE/SAGE SCOPES coverage.
Assist in supporting clinic staff and providers in proper workflows to satisfy SAGE/SAGE SCOPES
requirements in collaboration with the Clinical Quality Laision and Director of Quality.
Track positive iFOBt tests and process external referrals for colonoscopies from receipt to
completion for SAGE SCOPES.
Identify and analyze patient need for human papillomavirus (HPV) vaccine catchup for SCHS
pediatric population and provide patient outreach, patient/parent education, and staff
education.
Foster strong relationships with community partners to improve cancer screening rates.
To improve the health of our patients and communities by delivering exceptional care,
removing barriers and promoting healthy lifestyles.
Track qualitative data required for grant reporting around cancer screening and provide data to
Director of Quality upon request
Regularly attend and participate in the EHDI (Eliminating Health Disparities Initiative) grant
meetings and trainings; MDH SAGE meetings and clinical advisory group; attend and participate
in the monthly Quality Assurance Committee meeting upon request.
Assist with other duties and responsibilities as assigned.
KNOWLEDGE, SKILLS, AND ABILITIES:
Commitment to the SCHS mission and staff values.
Knowledgeable of the health care environment, specifically Federally Qualified Health Center.
Has continuous improvement and growth philosophy.
Attention to detail.
Self-directed and can interact professionally across multiple disciplines.
Excellent time management and organizational skills.
Works well both independently and as part of a team.
Exceptional communication and interpersonal skills.
Flexibility--nimble in response to an evolving workload.
Ability to exhibit good rapport with clients of varying professional and ethnic backgrounds and
socio-economic status.
MINIMUM QUALIFICATIONS:
Minimum of two years’ experience in a healthcare setting
Minimum of two years’ experience direct customer service, sales or patient care.
Strong office and administrative skills to include MS Office and other statistical programs.
Previous experience in an environment that provides direct patient care, case management,
and/or education.
Fluency (written and verbal) in English and Spanish preferred.
To apply: