 Work telephonically with patients identified as high risk for both behavioral and physical health issues, and their providers, to identify needs, set goals and implement action steps towards achieving goals. Empower patients to help them improve their quality of life and ensure an integrated approach to address complex issues. Understand and comply with NCQA guidelines and HEDIS measures. Comply with established referral, pre-certification and authorization policies, procedures and processes by related medical management staff.

 Engaged in population-based education, prevention and early intervention regarding behavioral health. Provided consultation and training to practice physicians and staff around the impact and management of patients’ psychosocial and care coordination needs. Utilized screening tools to identify patients in need of intervention. Initiated collaboration with consulting psychiatric provider, integrated case manager, substance use clinicians, and other providers across the regional network when indicated. Engaged patients in brief, targeted interventions to improve patient functioning and well-being. Provided referrals to outside providers when longer-term or more comprehensive treatment was indicated, bridging care until referral was complete. Provided education to patients regarding behavioral health issues, skill techniques, and practices to engage patients actively and positively in their own treatment and positive health outcomes.