Concert Health

Bilingual

• Provides care to patients, based on needs of assigned Care Pod, customizing treatment plan to individual patient needs
• Supports and closely coordinates behavioral health care with the patient’s primary care provider and (when appropriate) other service providers
• Screens patients for common behavioral health and substance use disorders using PHQ9, GAD7, Columbia Suicide Risk Assessment, or other tools as required
• Monitors patients for changes in clinical symptoms and treatment side effects/complications, with a goal of reduction in symptoms
• Supports psychotropic medication management prescribed by PCPs, focusing on treatment adherence, side effects and other complications, and treatment effectiveness
• Tracks patient follow-up and clinical outcomes using a registry, records encounters in the registry and uses the system to identify and re-engage patients
• Plans specific mutual self-management goals, objectives, and interventions with action-oriented patients
• Facilitates care plan changes for patients who are not improving, including changes in medications or psychosocial treatments or appropriate referrals for additional services
• Documents patient progress and treatment recommendations in Salesforce and the electronic health record so they can be easily shared with primary care providers, the psychiatric consultant, and other treating providers
• Completes relapse prevention plan with patients who are in remission
• Educates patients about behavioral health/substance use disorders and treatment options
• Establishes mutually agreeable care management plan with the care team and patient/family
• Participates in regularly scheduled caseload consultations with psychiatric consultants
• Participates in regularly scheduled supervision sessions with clinical supervisor
• Identifies social determinant barriers and works alongside the Care Navigation Partner to assist in providing access to the correct level of internal or external care

Bilingual Clinician, LMSW, LCSW, LPC – Behavioral Health

Medical Director

• Conduct weekly systematic case reviews (SCRs) with behavioral health care managers (Concert title: Collaborative Care Clinicians, CCCs) to provide psychiatric consultation and treatment recommendations
• Support diagnosis and suggest treatment plan changes, including medication and behavioral treatment recommendations
• Document workup and treatment recommendations to be implemented by the PCP in the electronic health record and communicate clinically-significant information directly to the PCP as indicated
• Collaborate with assigned CCCs to track and oversee patient panels and clinical outcomes using our cloud-based patient registry
• Perform a regular Patient Registry review of patients to identify high-risk patients, new patients, or those not improving as expected
• Provide real-time supervisory/consultation support to CCCs (outside of SCRs), other PCs, and PCPs as needed
• Supervise and provide clinical oversight to Psychiatric Nurse Practitioner PCs within their respective states, ensuring adherence to best practices and regulatory standards
• Collaborate with CCC leadership to mentor and support professional development of CCCs
• Identify opportunities for system improvement and contribute to internal best practices
• Oversee pod-level clinical quality assurance activities, including clinical performance monitoring, documentation review, and adherence to clinical protocols
• Serve as the primary medical liaison to the partner organization’s PCPs, medical directors, and clinical leaders
• Design learning agenda and lead educational sessions and case-based learning discussions with partner providers
• Travel to in-person meetings with partners as needed to foster collaboration, strengthen shared understanding, and support ongoing learning and improvement

Bilingual Clinician, LMSW, LCSW, LPC – Behavioral Health

Medical Director, MA License