Behavioral Health Complex Care Manager

POSITION SUMMARY:

The Complex Care Manager works with relevant stakeholders to identify and engage clients in intensive clinical care management with a focus on successfully addressing client’s behavioral health and social determinants of health, improving 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 position supports clients across Boston and will require in-person visits to members in the community.

Position:
Behavioral Health Complex Care Manager

Department:
Pop-Health Care Management

Schedule:
Full Time

• Identify and engage appropriate clients for complex care management from lists and referrals, in collaboration with supervisor and other program leads.
• 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
  • Refer clients to all necessary services including, but not limited to, medical treatment, behavioral health/substance use treatment, financial assistance, child-care, housing, food, clothing, vocational services, and transportation
  • 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, 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
• Provide mobile care management in the community to meet client’s needs including participating in off-site discharge planning meetings, and visiting clients at local programs, shelters or their homes if indicated
• Facilitates interdisciplinary consultation on client’s behalf through participation in team meetings, clinical reviews, and collaboration with client’s providers.
• Independently address client’s behavioral health crises by completing risk assessments, referring to appropriate levels of care, developing crisis treatment plans, and consulting with program manager when clinically indicated.
• Develop working relationships with collateral resources and other community service providers
• Participate in all training requirements and opportunities as designated by program manager
• Actively participate in growth and development
• Take lead on clinical needs of program caseload in absence of program manager and when indicated
• 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.

• Master’s Degree in Social Work or Counseling
• LCSW or LMHC preferred, but not required
• Experience providing case management services
• Experience working with vulnerable patient populations
• Experience working with clients with serious mental illness and/or substance use disorders

• 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…