HEDIS Outreach and Engagement Therapist at Mindoula Health

Mindoula is a next generation population health management company that identifies, engages, and serves populations with complex behavioral health, medical, and social challenges across the continuum of care. We deploy tech-enabled, multidisciplinary teams to deliver collaborative, measurement-based care to individuals who need it most.

The HEDIS Outreach & Engagement Therapist plays a pivotal role in improving behavioral health outcomes by (1) engaging patients with top-notch communication and highly professional customer service skills; and (2) delivering evidence-based therapy and supporting patients in the critical post-discharge period (7- and 30-day windows) as part of Mindoula’s and CareMind Health's integrated care approach. This individual will utilize a combination of patient engagement strategies, psychotherapeutic interventions, and validated screenings to ensure timely care post-discharge and to positively impact Mindoula partners’ HEDIS performance metrics.

This therapist must be clinically skilled, tech-savvy, highly organized, and able to communicate with empathy and precision. The position requires an ability to navigate electronic health records, manage multiple assessments, and work collaboratively across care teams to coordinate high-quality follow-up care.

What you'll do...

Patient Engagement & Therapy

• Initiate proactive outreach using a variety of technologies to recently discharged patients using care alerts, discharge lists, and referrals to schedule timely follow-up appointments.
• Conduct telehealth sessions for post-discharge behavioral health visits within 7 and 30 days to meet HEDIS criteria.
• Conduct and document screenings including, but not limited to, PHQ-9, GAD-7, M3, and Columbia Suicide Severity Rating Scale (C-SSRS) as part of intake and follow-up assessments.
• Provide evidence-based psychotherapy (individual) with a focus on patients recently discharged from inpatient behavioral health settings.
• Develop individualized, measurement-based treatment plans aligned with discharge goals and HEDIS targets.

HEDIS Measure Support

• Collaborate with discharge planners, inpatient facilities, and care coordinators to receive timely discharge notifications.
• Ensure documentation meets HEDIS standards by recording follow-up visits with appropriate diagnosis and clinical notes within the EMR within 24 hours.
• Track and report patient follow-up status, escalate missed appointments, and coordinate rescheduling.
• Review daily or weekly reports of eligible members needing follow-up appointments and initiate outreach.
• Participate in HEDIS training and remain updated on evolving regulatory and clinical requirements for 7- and 30-day behavioral health follow-up compliance.
  

Administrative & Collaborative Duties

• Maintain confidential, accurate, and timely documentation in EHR systems.
• Submit professional billing codes and charges daily.
• Connect the patient with in-network local behavioral health follow-up care as needed, including verifying that the provider has the appointment(s) scheduled.
• Engage in case conferencing with psychiatrists and the broader care team to coordinate care and reduce readmission risk as needed.
• Support new team onboarding and provide peer consultation when appropriate.
• Attend regular clinical supervision, HEDIS performance meetings, and staff training as required by both Mindoula and current and future Mindoula partners.
  
  

What you'll need...

• Master's Degree in Social Work, Counseling, Psychology, or a related field from an accredited institution.
• Active and unrestricted LMSW, LCSW, LCPC, LPC, LMFT, or equivalent clinical license required, or the ability to obtain within three (3) months of starting the position. Willingness to be licensed in other states, as needed, is required.
• Customer service experience
• Crisis intervention training and suicide risk assessment competency required.
• Minimum 2 years of experience in behavioral health clinical settings.
• Prior experience with HEDIS metrics or value-based care initiatives is highly desirable.
• Strong background in post-discharge planning, outpatient therapy, or transitional care preferred.
• Familiarity with EHR systems and ability to multitask across platforms.

Skills & Key Performance Indicators (KPIs):

• Strong clinical decision-making and risk assessment skills.
• Exceptional written and verbal communication abilities.
• Demonstrated experience using data to inform care and improve quality outcomes.
• Detail-oriented with excellent time management, especially in high-volume and time-sensitive situations.
• Culturally competent and sensitive to diverse populations.
• Strong commitment to ethical standards and patient confidentiality.