POSITION SUMMARY:

The Behavioral Health Complex Care Manager works with relevant stakeholders to identify and engage clients in clinical care management with a focus on patient experience, advancing health and reducing cost. The services focus on high risk and complex clients who have a pattern of inpatient admissions, high utilization of emergency services, difficulty engaging with outpatient treatment and may also be medically complex. The role requires assertive outreach, advocacy, service coordination, monitoring, follow up and general assistance to help clients manage barriers that may impede access to clinical services and progress in their recovery. This role is responsible for working with patients to identify strengths and barriers and to develop an individualized, patient-centered care plan. Excellent interpersonal skills, patient engagement skills and the ability to work independently and collaboratively are key requirements of the job. Clinical experience working with behavioral health conditions prevalent within the Medicaid population including psychotic disorders, personality disorders, and substance use disorders is necessary. Care managers collaborate closely with providers throughout the health system including outpatient therapists, psychiatrists, pharmacists, and PCPs as well as develop partnerships with other community resources.

Position: Behavioral Health Complex Care Manager

Department: Pop-Health Care Management

Schedule: Full Time

ESSENTIAL RESPONSIBILITIES / DUTIES:

Social Workers in all programs will be assigned to one of three clinical sites depending on the specific program they're a part of. Primary Care Practice, Emergency Department (ED), or Inpatient. Details on the 3 Care Management Programs are described below:

• Primary Care-based Complex Care Management: The CCM team will be embedded in local primary care practices. The team will partner closely with PCPs, Integrated Behavioral Health Professionals, Pharmacists, and other local resources in the Primary Care Practice to develop multi-disciplinary care plans. Social workers will proactively seek out opportunities to care for patients, including during PC visits, during ED or IP visits, out in the community, or on the phone. Social workers will work alongside Community Wellness Advocates and Nurses as indicated.
• Readmissions Care Team (RCT): The Readmissions Care Team is a multidisciplinary team of healthcare professionals that provides comprehensive, wrap-around care for patients during their inpatient stay and immediately after their discharge. The team specifically works with patients who have the greatest risk of readmissions. By complementing existing care teams on the inpatient and outpatient side, the Readmissions Care Team serves a critical role in connecting the dots across care providers and community agencies. The team works at inpatient facilities, and aims to fully integrate with inpatient care operations - documenting in local medical records, participating in care planning efforts, etc. to ensure seamless care planning for patients while also serving as the link to continuing outpatient care.
• Behavioral Health Consultation: In this consultative role, social workers will utilize their clinical assessment skills and expertise in BH system navigation to support multiple care management teams. Consultation will consist of completing risk assessments, biopsychosocials, and referrals to all level of psychiatric and addiction treatment. This work will be completed primarily through telephonic and virtual support to teams, as well as ongoing development of clinical resources within the identified region.

Key Functions/Responsibilities:

• Identify and engage appropriate clients for complex care management from lists and referrals, in collaboration with supervisors and local site leaders
• Ability to execute core care management duties:
  • Comprehensive assessment: bio-psycho-social-spiritual
  • Collaboration with client and care team to develop client-centered care plan
  • Implementation of care plan
  • Provide consistent outreach and support services to enable clients to utilize clinical treatment
  • Monitor clients utilization of care across the care continuum, including Emergency Department Visits and inpatient admissions
  • Collaborate with community partners, such as medical providers, VNA agencies, substance use disorder/mental health service providers, and social service agencies;
  • Assessment of goal completion, with transition of client to ongoing supports upon graduation from program
• Uses reflective, empathetic language and open-ended questions to understand what the patient truly wants for him/herself beyond being healthy and staying out of the hospital
• Meet the patient where he/she is; observe the patient without intervention or judgment
• Meets regularly with leaders at the local clinical site (Primary Care, ED, inpatient), and care management supervisor, to triage program issues appropriately.
• Participates in local site operations, including team meetings, curbsides with care team members, etc.
• Actively participates in planning and growth of program with relevant stakeholders as needed, to respond to evolving needs of MassHealth ACO.
• Facilitates interdisciplinary consultation on patient's behalf through participation in rounds, team meetings and clinical reviews
• Complies with established metrics for performance and adheres to documentation and work flow standards including clearly documenting all progress and submitting accurate billing within expected time frames
• Utilizes the electronic health record and other IT interfaces as necessary to track and monitor patients
• Maintains HIPAA standards and confidentiality of protected health information.
• Adheres to departmental/organizational policies and procedures.

JOB REQUIREMENTS

EXPERINCE/EDUCATION:

• Master's Degree in Social Work or Counseling or pending Master's Degree in Social Work or Counseling
• Preference for independently licensed clinicians (LICSWs), will consider LCSW and license eligible based on additional work experiences
• Experience providing case management services
• Experience working with vulnerable patient populations
• Experience working with clients with serious mental illness and/or substance use disorders

KNOWLEDGE AND SKILLS:

• Strong understanding and familiarity with common diagnoses across behavioral health and medical settings
• Strong understanding and familiarity with levels of care and how to navigate behavioral health system
• Extensive knowledge of healthcare systems and relevant community resources
• Sensitivity to ethnic, cultural, gender, and sexual orientation diversity, values, beliefs, and behaviors
• Excellent interpersonal skills and ability to work collaboratively
• Self-management skills, including ability to prioritize and set patient-centered goals
• Excellent written and verbal communication
• Able to maintain professional boundaries
• Ability to work with diverse, safety-net population
• Skilled at engaging difficult to engage patients-build rapport, trust
• Ability to work in a fast paced environment, inclusive of organizational skills, time management skills, critical thinking, and problem solving abilities
• Computer competency, inclusive of the ability to access and enter data through the electronic medical record system, submit billing, assist clients with scanning/faxing/printing and manage personal email system
• Bilingual or multi-lingual skills (beyond that of English) appropriate to the patient population serviced, is preferred

Req id: 29897