| Name of Organization: | Primary Care IPA |
| Job Title: | Pediatric Behavioral Health Coordinator |
| Part-time or Full-time: | Full-time |
| Job Location: | Buffalo, NY |
| Start Date: | Monday, May 2, 2022 |
| Job Description: | Position Summary: Primary care reimbursement is undergoing major transformation as payment models align toward value-based care arrangements that reward higher quality, more efficient care delivery. At the core of this transformation is the ability to work with data to understand who our patients are, identify who needs special intervention, and target clinical programs that will drive better health outcomes for our patients. The IPA has engaged HEALTHeLINK, the regional health information organization, to utilize HEALTHeOUTCOMES (HeO), their population health application. The primary objective of this position is to devise and standardize clinical and administrative strategies to optimize patient health outcomes, patient experience, and financial sustainability. Interventions may include but need not be limited to physician directed, interdisciplinary plans of care developed in collaboration with patients to ensure patient self-management. Development of strategic partnerships is an essential part of this position. This will include identifying service providers within the community (medical sub-specialists, hospital systems, social service organizations and mental health organizations) that are in alignment with the Primary Care Plan of Care and establishment of referral agreements which support them. The CCC will work closely with the rest of the IPA’s clinical team, the Clinical Integration Team (CIT), and with the Chronic Care Managers (CCMs) at IPA practices to focus targeted resources on high acuity patients in a standard, coordinated manner. The incumbent will be informed by the IPA’s clinical analytics team as to which patients require the most intense intervention based on their clinical status, and then collaborate with practice physicians and CCMs to ensure these patients are promptly seen, and that physician-directed care plans regarding medications, diagnostic testing, additional visits, telephonic follow-up, remote monitoring, patient education, specialist referrals and use of available community resources are organized, implemented, monitored, and corrected effectively. Responsibilities and Duties: • Based on criteria developed by data analytics team, collaborates with providers and practice staff in identifying appropriate patients for care management. • Prioritize patients according to health complexity and level of need for support. • Working with the IPA clinical staff, the CIT, and practice CCMs, establish a standard care management protocol for targeted patient populations. This would include: o Annual whole-health assessments to determine Plan of Care and periodic follow up assessments to measure progress and adjust, as necessary. o A standardized tool for collecting health data, identify opportunities for improvement and to measure improvement for each patient. o Standard process for the establishment of a care management plan that is mutually agreed upon by the health care team and the patient/family. Plan includes specific mutual self-management goals and objectives. o Disease-specific patient education material, including the importance of self-management and lifestyle changes. o Developing interventions with the patients that are action oriented. o Collaborate closely with other members of the IPA Clinical Support Team: Pharmacists, Social Workers, Data Analysts, Nurse Care Coordinators to develop standardized tools and resources and assist in the implementation of processes to support member groups in managing patients with complex health conditions. o Engaging the IPA Clinical Pharmacy team to make medication adjustments as needed in collaboration with Primary Care Provider. o At the direction of the physician, assist in determining and referring to appropriate specialty care. o Support member practices in identifying and creating a resource list of collaborative care service providers in the community and establishing processes that streamline coordination of care. o Collaborating with member practices on a standardized periodic review and amendment of the plan of care, initiating care conferences to discuss multidisciplinary team responsibilities, patient progress, new problems, etc. o Facilitating patient access to community resources as appropriate or refers to LSW. o Identifying processes to promote patient self-management and empower patients/families to achieve maximum levels of wellness and independence. o Implementing Transitions of Care standards to facilitate care coordination across the health care continuum and optimize clinical and financial resources. • Directed by the CIT and practice physician leadership, customizes the implementation of the standard care management protocol with each IPA practice, considering practice resources and constraints. • Works with the practice CCMs, evaluates the effectiveness of the protocol in meeting practice and IPA quality and efficiency goals; revises as needed to reflect changing needs, issues, and goals. • Monitors and evaluates the progress of the patient population according to care plan objectives, and practice and IPA quality and efficiency metrics. • Reviews quality reports routinely and scans for gaps in care and to identify patients needing additional support and coordinates interventions with practice CCMs. • Maintains a working knowledge of payer requirements, HEDIS measures, and the differences in metric calculation. • Develops collaborative working relationships with IPA practice and insurance care managers. • Participates in IPA level clinical process development and leads efforts as directed. • Supports the work of the adult and pediatric CIT. • Meets with the care management team leader (Clinical Primary Care Pharmacist) and the care management team on a regular basis to provide patient population updates, identify issues and develop strategies for resolution. • Maintains a working knowledge of, and adheres to applicable federal and state regulations including, but not limited to, laws related to patient confidentiality, release of information and HIPAA. • Performs other duties as assigned. |
| Required Qualifications: | • BSN or MSW required. • Minimum of one year of pediatric experience. |
| Preferred Qualifications: | Minimum of three years pediatric experience preferred; primary care experience preferred. |
| Rate of Pay: | $65,000-$75,000 range depending upon experience |
| How to Apply: | https://www.linkedin.com/jobs/view/2989132198 or send cover letter and CV to: hstahlnecker@primarycareipa.org |
| Contact: | Heidi Stahlnecker (hstahlnecker@primarycareipa.org) |
| Website: | https://primarycareipa.org/ |
