Do you want to make a difference in healthcare?
Landmark Health was created to transform how healthcare is delivered to the most medically vulnerable members in our community. Our medical group provides home-based medical care to chronically ill patients, many of whom are frail, elderly and ill-equipped to navigate our overwhelming healthcare system.
Because many of our patients are frail and elderly, we deliver care primarily in the comfort of their home. Our Program is also offered to eligible patients at no incremental financial cost to them. We are not a fee-for-service practice; we benefit economically only if we deliver high-quality patient outcomes and satisfaction. As a result, our clinical teams can spend quality-time caring for a smaller number of patients, giving all patients the space, respect, compassion and care they deserve.
Our model is finding success throughout the country; we are now the nation's largest risk-based, in-home medical group.
At Landmark, our interdisciplinary teams collaboratively manage our complex patient panels. These teams are led by Physicians, Nurse Practitioners, and Physician Assistants, with supporting care provided by RN Nurse Care Managers, Social Workers, Pharmacists, Behavioral Health and other employed team members.
The behavioral health care manager (BHCM) is a core member of the collaborative care team, including the patient's longitudinal medical provider and behavioral health consultant, as well as the larger interdisciplinary team (IDT). The BHCM is responsible for supporting and coordinating the mental and physical health care of patients on an assigned patient caseload with the patient's longitudinal provider and, when appropriate, community behavioral health providers.
This position is a mixture of in home visits and telephonica calls to patients
- Support the mental and physical health of Landmark patients on an assigned patient caseload.
Closely coordinate care with the patient's longitudinal Landmark provider and, when appropriate, community behavioral health providers.
Screen and assess patients as well as provide patient education for common behavioral health and substance use disorders. Facilitate patient engagement and follow-up care.
Systematically track treatment response and monitor patients (in person or by telephone) for changes in clinical symptoms and treatment side effects or complications.
Support psychotropic medication management as prescribed by the longitudinal Landmark provider, focusing on treatment adherence monitoring, side effects, and effectiveness of treatment.
Provide brief behavioral interventions using evidence-based techniques such as behavioral activation, problem-solving treatment, motivational interviewing, or other interventions as appropriate until linkage to a community provider.
Provide or facilitate community referrals to evidence-based psychosocial treatments (e.g. problem-solving treatment or behavioral activation) for on-going treatment as clinically indicated.
Participate in regularly scheduled (usually weekly) caseload consultation with the behavioral health consultant and communicate resulting treatment recommendations to the patient's longitudinal Landmark provider. Consultations will focus on patients new to the caseload and those who are not improving as anticipated under the current treatment plan. Case reviews may be conducted by telephone, video, or in person.
Track patient follow-up and clinical outcomes using a dashboard built into the Electronic Medical , Ubiquity. Document in-person and telephone encounters in the EMR and use the system to identify and re-engage patients.
Document patient progress and treatment recommendations in the EMR to be shared with the longitudinal Landmark provider, behavioral health consultant, and other IDT members.
Facilitate treatment plan changes for patients who are not improving as expected in consultation with the longitudinal Landmark provider and the behavioral health consultant and who may need more intensive or more specialized behavioral health care.
Facilitate referrals for clinically indicated services outside of Landmark Health (e.g., social services such as housing assistance, vocational rehabilitation, mental health specialty care, substance use disorder treatment).
Develop and complete a relapse prevention self-management plan with patients who have achieved their treatment goals and are soon to be discharged from the caseload.
Demonstrated ability to collaborate and communicate effectively in an interdisciplinary team setting
Ability to maintain effective and professional relationships with patients and members of the care team
Experience with screening for common mental health and/or substance abuse disorders
Working knowledge of differential diagnosis of common mental health and/or substance abuse disorders, when appropriate
Ability to effectively engage patients in a therapeutic relationship, when appropriate.
Ability to work with patients by telephone, video, as well as in person.
Experience with assessment and treatment planning for common mental health and/or substance use disorders
Working knowledge of evidence-based psychosocial treatments and brief behavioral interventions for common mental health disorders, when appropriate (e.g., motivational interviewing, problem-solving treatment, behavioral activation)
Basic knowledge of psychopharmacology for common mental health disorders that is within appropriate scope of practice for training of provider filling role
Experience with evidence-based counseling techniques
At least three years post Master's experience in case management of patients with behavioral health needs
Access to reliable transportation to conduct meetings within the community required; if you are driving a vehicle, you must comply with all the terms of the Landmark Motor Vehicle Safety policy
TRAINING & LICENSURE REQUIREMENTS
Licensed Independent Social Worker - LISW in OHrequired
In order to work with potentially vulnerable patient populations and to keep employees healthy while caring for patients, all patient-facing employees of Landmark must provide evidence of the following required immunizations/vaccinations as a condition of employment: TB, MMR, Tdap, and Influenza. Declinations may be accommodated based on your medical history, an allergy or religious beliefs. Please immediately contact HR if you wish to apply for an exemption from our vaccination requirements so that we may determine if you qualify for an accommodation.
Full COVID-19 vaccination is an essential requirement of this role. Landmark Health will adhere to all federal, state and local regulations as well as all client requirements and will obtain necessary proof of vaccination prior to employment to ensure compliance.
We are now part of Optum and the United Health Group family of businesses, backed by the resources of a global health organization working to help people live healthier lives and to help make the health system work better for everyone.
As part of our hiring process, upon accepting an offer, candidates will be required to complete a 9-panel drug test. Due to our partnership with the Medicare Advantage program, our drug testing policies are consistent with Federal law.
Please be aware that Landmark Health does not solicit money or offer payment for job applications, nor do we ask candidates to email or submit any personal information over unsecured channels.
Landmark Health requires all new hires and employees to report their COVID-19 vaccination status.