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Establish and maintain connection with Primary Care Physicians in the area for referral and collaboration purposes.
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Works closely with the Behavioral Health Home Director, Administrative Support, Clinical Supervisor and Primary Addiction Counselor to ensure that referred patients enroll and receive monthly services and periodic outcome evaluations.
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Incorporate individualized behavioral health goals into the patient's existing care plan. Review/update with the patient at least every 6 months.
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RN Nurse Care Manager will also have a working knowledge of e-Medicaid (billing system) for Behavioral Health Home), be able to complete billing functions when needed, and provide accurate billing information to Health Home Care Coordinator.
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Create a tracking system to ensure that each patient participant has (2) billable services per month.
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Be able to maintain and extract monthly data reports from E-Medicaid as well as review consistently the data system for accuracy of patient demographic and service delivery for billing purposes.
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Complete face to face sessions with patients and families as needed, both in office and in the community, to review health goals, provide education, and assess/document the patients Stages of Change.
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Collaborate and advocate for patients' medical needs, including PCP (primary care providers), dental, specialist, mental health providers, etc.
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Facilitates medical care through ongoing, proactive follow-up with patients to ensure they can follow through with referrals. Communicates and coordinates with the referral site to ensure recommendations and treatment are shared with the referring site.
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Collaborates with the New Hope clinical staff regarding patient care, goals, and coordination of appointments.
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Assist Addiction Counselors with education material for face-to-face sessions.
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Plan/Schedule/Facilitateschedulededucationalgroupsi.e.(polypharmacy, influenza, Hep C, etc.).
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Demonstrates the knowledge and skills necessary to provide care appropriate to adult Health Home consumers.
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Demonstrates knowledge of the principles of growth and development of the lifespan and possesses the ability to assess data reflective of the Behavioral Health Home consumers status and interprets the appropriate information needed to identify each consumer's requirements relative to his or her age, specific needs and to provide the care needed as described in departmental policies and procedures.
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Provides patient care to adults enrolled in the Behavioral Health Home program.
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Performs other duties and special projects as assigned by the Behavioral Health Home Director.