Behavioral Health RN Care Manager



Customer Service
Westlake, OH, USA
Posted on Saturday, September 16, 2023
Location: Premier Physicians Centers Inc.
Position Title: Behavioral Health RN Care Manager
Reports To: Director, Value Based Transformation
FLSA Status: Exempt
Overview: The Behavioral Health RN Care Manager collaborates with health care providers to meet identified complex and episodic medical and social needs of the patient and to promote the efficient and cost-effective delivery of health services. The Behavioral Health RN Care Manager is responsible for providing developmentally appropriate mental health services/care management to patients within an integrated healthcare and wellness model also incorporating the disease management of patients with chronic conditions.

Essential Functions:

  • Makes transition calls to discharged patients within the designated time frames and documents and tracks findings.
  • Initiates or accepts referrals from staff for patient needs assessment, determines eligibility for resource assistance, and makes resource referrals.
  • Provides follow up with individual patients, their families, and referral resources to ensure contact has occurred and patient needs have been met within limits.
  • Establishes/maintains positive, ongoing working relationships with other community agencies, physician offices.
  • Establishes and maintains effective network of community resources for cross-referral of patients.
  • Develops and maintains a current resource directory for a wide range of support services.
  • Provides current and appropriate general health and wellness education throughout interaction with patients as well as teaches self-management skills.
  • Works closely with physicians, nurses and other medical staff to communicate a patient’s needs and concerns.
  • Contacts patients for transition of care or follow up care, assesses their needs, identifies gaps in care, implements care plans if needed, notifies physician of findings.
  • Utilizes effective interviewing techniques with strong limit setting abilities.
  • Provides regularly scheduled collaborative care team meetings.
  • Positive, flexible, and solution-focused attitude.
  • Travel may be required to multiple office locations to meet with care team and patients.
  • Effectively communicates with the disabled and elderly populations and general public, both in person and by phone.
  • Communicates in a collaborative, effective manner with others and maintains good working relationships; able to establish rapport quickly with a wide range of people.
  • Provides leadership for new or less experienced team members by training, developing, coaching, mentoring and being a positive role model.
  • Assesses for potential barriers and provides resources or referrals as needed.
  • Reviews hospital discharge information, assesses patient understanding, and provides education as needed. Follows up with patients to assure their needs are still being met after discharge.
  • Provides referrals, education to patients upon their transition and in an outpatient setting.
  • Identifies patients that may need care management services.
  • Uses clinical judgment, critical thinking and problem-solving techniques when assessing patients in order to promote optimum patient outcomes and decrease potentially preventable ED visits or hospital admissions/readmissions.
  • Provides ongoing care management for a diverse population of persons with chronic illnesses or disabilities of all types.
  • Evaluates and develops care plans for care managed patients based on patient needs; collaborates with team as needed.
  • Identifies and documents psychosocial needs; sends community referrals as needed and monitors for responses.
  • Identifies gaps or barriers in self-management and provides education to assist as needed.
  • Works with patients to close gaps in care; addresses barriers that may impact gap closure
  • Coordinates patient services as needed.
  • Uses oral and written communication to convey pertinent information to members of the health care team in a timely manner.
  • Educates patients on disease processes, health maintenance, medication management and self-management skills.
  • Encourages patients to make healthy lifestyle changes.
  • Utilizes a positive proactive approach to function as a health advocate to engage patients.
  • Interacts with the care team on challenging cases.
  • Separates personal from professional interactions with patients and maintains professional/ethical boundaries.
  • Follows “best practice”, policies, and procedures.
  • Participates in continuous quality improvement to enhance care transition and care management of patients.
  • Maintains required documentation for all care transition and care management activities.
  • Maintains consumer confidentiality according to HIPAA privacy rule.
  • Works with leadership to continuously evaluate processes, identify problems, and propose/develop process improvement strategies.
  • Participates in regularly scheduled team and inter-organizational meetings.
  • Remains organized; prioritizes and communicates effectively to patients, families, clinicians, and team members.
  • Assesses the healthcare, educational, and psychosocial needs of the patient/family.
  • Provides self-management support and empowers the patient to achieve optimal health and independence.
  • Uses appropriate behavioral health nursing skills to meet the unique needs of each patient.
  • Assists as needed to ensure smooth functioning of the department. Experience / Education Requirements:
  • Active, clear, unrestricted Ohio RN license
  • Minimum level of education desired for candidates in this position is an Associate degree or an equivalent combination of education and experience may be considered.
  • At least two years of professional experience (post-licensure) working with individuals with behavioral health, physical and behavioral disabilities, medically ill; prior behavioral health environment experience is required.
  • Ability to work independently under general instructions, self-directed and motivated.
  • Excellent verbal and written interviewing and assessment skills.
  • Knowledge of major chronic disabling illnesses for persons of all ages, disease processes, and normal aging.
  • Experience with Microsoft Office, proficient typing skills with the ability to navigate a Windows environment.
  • Ability to analyze, evaluate, and implement a reasonable course of action based on available information.
  • Ability to comprehend written material related to essential job functions.
  • Demonstrates the ability to handle stressful situations appropriately.
  • Demonstrates the ability to work as part of a team.
  • Demonstrates the ability to function effectively in a fluid, dynamic, and rapidly changing environment.
  • Demonstrates patient focused interpersonal skills to interact in an effective manner with practitioners, the interdisciplinary health care team, community agencies, patients, and families with diverse opinions, values, religious and cultural ideals.
  • Strong organizational skills and multitasking abilities.
  • Sensitivity and experience in working with different cultures.
  • Demonstrates excellent written, verbal, telephonic, interpersonal and listening communications skills; positive relationship building.
  • Serves as a resource to other team members.
  • A personal vehicle, valid State of Ohio motor vehicle operator’s license and conformity with insurance coverage limits are required.
  • Supervisory Responsibilities: None

Value Based Transformation Team Mission:

  • Healthcare is a field of rapid change affecting all aspects of patient health. Our department embraces change, continually evaluating ourselves and our processes, to assure we are bringing the highest quality of care to our patients. We continue to learn and grow, realizing that when change is for the right reason, it is extremely gratifying and rewarding. Developing this culture of quality & excellence, providing “Premier Care” to our patients, is our mission.


  • As a group medical practice required to comply with HIPAA and other state and federal compliance standards, employee must agree to follow company’s written policies designed to maintain such compliance. Position will have access to Protected Health Information (PHI) and employees are to access only the information necessary to fulfill specific job requirements, including special assignments. Please refer to Premier Physicians Centers HIPAA Manual for complete policies and procedures.
Please note this position is posted on behalf of our partner practices. This individual will be working at the specific practice that is mentioned in the above details and will not be a direct employee of Aledade, Inc. so will therefore not be eligible for the benefits available to Aledade employees.