want to make a difference in healthcare?
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.
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
model is finding success throughout the country; we are now the
nation’s largest risk-based, in-home medical group.
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.
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
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
? 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
? 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
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
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
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
& LICENSURE REQUIREMENTS
Licensed Clinical Social Worker - LICSW in WA required
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.
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
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.
requires all new hires and employees to report their COVID-19