This position is responsible for communicating with patients, providers, and UHACO staff in support of population management activities for University Hospitals Behavioral Health Service. This position is primarily based within University Hospitals Behavioral Health Ambulatory Outpatient Services.

What You Will Do

• Analyzing data sources to identify at-risk patients and assist in developing specific care plans to address health concerns, gaps in care (ex. such as medication adherence) and other challenges.
• Working remotely and under minimal supervision in a professional environment, provide patient education, connect patients with available resources within UHACO, UH, and in the community to assist patients in identifying and overcoming barriers.
• Participate in daily outreach to patients to schedule BH appointments for various behavioral health services document all outreach to patients using required systems and workflows
• Educate patients and families to make informed Behavioral Health care decisions. Providing culturally competent care and support/coaching to patients, their families and providers in addressing medical and social concerns.
• Facilitating communication between patients, providers, health plan and the community leveraging motivational coaching for behavioral change and assisting in facilitating communication and appropriate referrals between plan members and UHACO staff.
• Provide ongoing outreach to patients to support scheduling of BH services and monitor for patient status, including to work with provider to ensure patient seen based off of provider consultation and treatment recommendations, communication with beneficiaries as necessary, and document appropriately.
• Maintain and document patient progress through individual care plan and adherence to specified criteria. Following call scripts and pre-defined processes to conduct outreach.
• Helping to organize and facilitate appropriate portions of team meetings, being involved in office meetings and planning sessions.
• Help coordinate individual patient care by partnering with providers to develop individual, trusted, relationships with patients focused on guiding the patient through: diagnostics services, utilization of specialty care services, community agencies, scheduling issues
• Conduct thorough patient chart reviews and data abstraction to ensure accurate documentation and compliance with healthcare standards, enhancing patient care coordination and outcomes.
• Participate in quality improvement initiatives to enhance patient documentation, patient satisfaction, and patient outcomes and assisting with quality reporting and documentation.

Additional Responsibilities

• Performs other duties as assigned.
• Complies with all policies and standards.
• For specific duties and responsibilities, refer to documentation provided by the department during orientation.
• Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace.
• Performs other duties as assigned.
• Complies with all policies and standards.
• For specific duties and responsibilities, refer to documentation provided by the department during orientation.
• Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace.