Imagine Pediatrics
BehavioralHealthCareCoordinator
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“Behavioral Health Care Coordinator at Imagine Pediatrics. Skills: Behavioral Health Care Management, Case management for children with special healthcare needs, Monitoring high-risk pediatric patients, Conducting comprehensive assessments, Providing referrals, Daily tracking of family needs, Modifying care plans, Clinical documentation, Interventions aligned with social, emotional, and physical needs, Escalating high-risk patients, Facilitating case management, Researching and resourcing externa”
What You'll Achieve.
Ensuring appropriate follow-up and assistance with meeting resource needs; Continuously evaluate the effectiveness of the patient/family care map; Modify plans based on evolving needs and goal progression; Close patient visits and charts within required timeframes
Industry & Context.
Assessment of needs; Modifying plans based on evolving needs and goal progression; De-escalation of mental health crises; Behavioral issues; Family conflicts; Navigating the complexities of mental health diagnoses; Research and resource validated external services
Role is remote with 10% travel necessary for training/education purposes, Ability to work afternoons and evenings
What They're Looking For.
Must Have
Masters’ degree with major course work in social work or related field, 3-5 years of post-graduate experience in health care social work/Case management in behavioral health, Experience working with pediatric population and family systems, Proficiency in motivational interviewing practices and/or goal setting and assessment of needs, Knowledge of social work including crisis prevention and intervention, Experience with providing telehealth services, Ability to work afternoons and evenings
Nice to Have
Provisional licenses (LMSW, PLPC, LAMFT), Bilingual Spanish, knowledge of behavioral health principles and practices, Proficient in trauma-informed care practices, knowledge of mental health common signs and symptoms and able to identify difficulties with coping
What You'll Do.
Monitor high-risk pediatric patients (up to 21 years old)
including those recently discharged from the hospital
ensuring appropriate follow-up and assistance with meeting resource needs (food
Conduct comprehensive assessments to address behavioral
and systemic needs of patients and provide referrals based on identified and ensure caregivers and patients receive prompt
coordinated communication.
Perform daily tracking of family needs
continuously evaluate the effectiveness of the patient/family care map
and modify plans based on evolving needs and goal progression.
accurate clinical documentation for each patient.
Utilize Athena and other internal systems to close patient visits and charts within required timeframes.
Provide interventions aligned with the social
and physical needs of patients and caregivers
including de-escalation of mental health crises
and family conflicts.
Escalate high-risk patients through appropriate pathways.
Facilitate case management requiring clinical expertise across various systems
helping patients and families navigate the complexities of mental health diagnoses.
Research and resource validated external services to meet behavioral and social needs
including social services agencies and behavioral health specialists.
Provide psychoeducation on mental health diagnoses
treatment progression
the importance of treatment adherence
and related topics as appropriate.
Collaborate regularly with external care team members
including school systems
and respective state department of child welfare as needed.
Participate in scheduled interdisciplinary team consultations to monitor patient progress.
Represent Imagine Pediatrics professionally to patients
and the broader community.
Perform other duties and responsibilities as assigned by manager.
How You'll Work.
Team & Collaboration
Work alongside pediatricians, nurses, care coordinators, and other healthcare professionals.; Collaborate regularly with external care team members, including school systems, specialists, and respective state department of child welfare as needed.; Participate in scheduled interdisciplinary team consultations to monitor patient progress.; Represent Imagine Pediatrics professionally to patients, families, providers, and the broader community.; One Team, Diverse Perspectives: Actively seek a range of viewpoints to achieve better outcomes. Even when we see things differently, we stay aligned on our shared mission and support one another to move forward — together.
Communication Scope
Prompt, coordinated communication; Represent Imagine Pediatrics professionally
Full Job Description
Who We Are Imagine Pediatrics is a tech enabled, pediatrician led medical group reimagining care for children with special health care needs. We deliver 24/7 virtual first and in home medical, behavioral, and social care, working alongside families, providers, and health plans to break down barriers to quality care. We do not replace existing care teams; we enhance them, providing an extra layer of support with compassion, creativity, and an unwavering commitment to children with medical complexity. The primary location for this role is remote, and expected schedule requirements are Monday to Friday, 8:00am - 5:00pm eastern and 10:30 am - 7:00pm eastern. What You’ll Do As a Behavioral Health Care Manager (BHCM) at Imagine Pediatrics, you will work with the families of children with special healthcare needs, providing case management services for members enrolled in Imagine Pediatrics care model. You will work alongside pediatricians, nurses, care coordinators, and other healthcare professionals. Your primary responsibilities will include: Monitor high-risk pediatric patients (up to 21 years old), including those recently discharged from the hospital, ensuring appropriate follow-up and assistance with meeting resource needs (food, housing, etc). Conduct comprehensive assessments to address behavioral, social, emotional, and systemic needs of patients and families; provide referrals based on identified needs; and ensure caregivers and patients receive prompt, coordinated communication. Perform daily tracking of family needs, continuously evaluate the effectiveness of the patient/family care map, and modify plans based on evolving needs and goal progression. Maintain timely, accurate clinical documentation for each family; utilize Athena and other internal systems to close patient visits and charts within required timeframes. Provide interventions aligned with the social, emotional, and physical needs of patients and caregivers, including de-escalation of mental health
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