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Clinical Care Manager Population Health (LCSW, LICSW, LMHC)

Job ID 147838 Date posted 07/07/2018

The Behavioral Health Community Partner (BHCP) program at Lahey Health Behavioral Services is a new, innovative Care Management program for MassHealth members that are part of the new Accountable Care Organization (ACO) and or a Managed Care Organization (MCO). The Clinical Care Manager is part of a multidisciplinary team and will play a key role in providing clinical oversight and integrated care to the BHCP enrollees with complex medical, behavioral health and social needs. The Clinical Care Manager, under the direction of the BHCP Director and in collaboration the RN Care Manager, will be a key contributor to the Care Planning process. Responsibilities include providing supervision of the care coordinators and ensuring compliance with BH CP contractual agreements. Work directly with providers, patients, families and caregivers. Will use expertise to assess and identify needs and connect patients to appropriate clinical and community resources and with the goal of improving overall BH CP performance on quality measures across the following domains: Prevention and Wellness, Chronic Disease Management, Behavioral Health/Substance Use Disorder, Member Experience, Integration, Avoidable Utilization and Engagement.


Ensure adherence to all policies and procedures relative to outreach and engagement, care coordination, care management, and care transition functions and activities;

Assign new cases to Care Coordinators (CC) and conduct regular compliance audits of client records, assisting with record management and data collection.

Facilitate consents, gathering of clinical information (including all existing medical, behavioral health and treatment plans) and discussion with enrollee?s BH and medical providers

Conduct outreach and outreach engagement activities and provide information about the benefits, design and purpose of the CP Supports

Responsible for maintaining required staffing to meet enrollee coverage outlined in the BHCP performance specifications.

Assume the lead responsibility for the forming and operation of a Care Team for each engaged Enrollee

Works closely with patients, collaborating with them and Care Team to develop and implement a Care Plan that will address their unique needs with the goal of improved self-care and decrease the need for urgent care for this behavioral health population.

As a key member of the Care Team, will see patients in a variety of settings including ED, hospital, outpatient settings, clinics and contact telephonically on a regular basis to assess their progress and revise the plan of care as needed. Ensures communication and understanding of treatment plan among patient, family and health care team members.

Facilitate communication among and coordinate with the Engaged Enrollee, the PCP, and other providers who serve the Engaged Enrollee

Execute the activities necessary to support the Engaged Enrollee?s Person-Centered Treatment Plan and to ensure the Engaged Enrollee has timely and coordinated access to primary, medical specialty, LTSS, and behavioral health care

Prior to an Engaged Enrollee?s inpatient discharge or change in treatment setting, assist in the development of an appropriate discharge plan, in coordination with the Engaged Enrollee, the Engaged Enrollee?s PCP, ACO, MCO and other providers, as appropriate.

Regularly perceives potential problem situations and intervenes to offset adverse impact, demonstrates proactive attitude. Utilizes established protocols and collaborates with health team utilizing a person-centered framework to facilitate therapeutic interventions and attainment of desired patient outcomes. Advocating for patient and caregiver needs in inpatient, outpatient, home, and community settings.

Develop and maintain collaborative relationships with community based organizations in the Contractor?s Service Area

Facilitate enrollee referrals to resources including medical appointments as directed by the CP and conduct ongoing follow-up

Have in-depth knowledge of local resources. Experience with accessing resources and substance abuse treatment a priority.

Demonstrates excellent communication, documentation, time management and organizational skills.

Oversee the coordination and provision of integrated rounds meeting as scheduled or as requested;

Provide direct supervision to lead care coordinators. Continuously assess learning needs of supervisee; develop and implement training learning objectives and supervision plan; complete performance reviews as required.

Responsible for monitoring and ensuring that supervisee?s paperwork is timely and written in an accurate, legible and concise manner (including proper completion of billing paperwork). Ensures supervisee?s records are in compliance with the organizations methods of Quality Assurance.

Meet monthly productivity expectations and ensure CCs meet productivity expectations in relation to clinical services provided.

Develop and maintain collaborative relationships with community based organizations in the NE region and state agencies, including as applicable the Executive Office of Elder Affairs (EOEA), the Department of Children and Families (DCF), the Department of Mental Health (DMH), the Department of Developmental Services (DDS), the Department of Public Health (DPH), the Massachusetts Rehabilitation Commission (MRC), the Massachusetts Commission for the Deaf and Hard of Hearing, and the Massachusetts Commission for the Blind;

Complete all clinical documentation (intake packets, termination/transfer, billing sheets, insurance forms etc.) within expected timeframes and in compliance with organization policies. Documentation must meet quality standards established by regulatory bodies and the agency.

Carries out supervisory responsibilities in accordance with the Lahey policies and procedures and applicable laws. Responsibilities include supporting the BHCP Director with interviewing, hiring and training employees; performance management; addressing complaints and resolving problems.

The position does not have direct budgetary management; however in conjunction with the BHCP Director should have awareness of fiscal requirements and be able to disseminate accurate financial information to when appropriate.

Utilizes active listening and gets clarification when needed; responds appropriately to questions. Writes clearly and informatively. Responds to common inquiries and complaints from clients, regulatory agencies, and other service providers. Defines problems, collects data, establishes facts and draws valid conclusions.


Master's degree in human services field, four years post-masters experience. Minimum two years of supervisory experience.

A qualified candidate must be licensed at one of the following levels; LCSW, LICSW, LMHC, Occupational Therapists, or Licensed Rehabilitation Counselors (LRCs)

3-5 years related experience in delivering community based services.

Knowledge of commercial behavioral healthcare practices, evidenced based treatments, managed care principles, provider development and quality improvement concepts is essential. Familiarity with state and local agencies serving the community helpful.

Flexibility: willing to see clients in clinic-based setting and/or in community or school; some expectation of working evenings. Ability to provide leadership, accept responsibility, work independently and set own goals in a professional manner.

Ability to exercise good judgment clinically, legally and ethically and to consult with supervisor as needed.

Proficiency with electronic health record documentation or ability to complete documentation electronically is required. Working knowledge of standard desktop applications such as Windows and Microsoft Suite



Scheduled Hours

40 hours, full time

Physical Requirements

Must be able and willing to transport enrollees served. As such, must have a valid driver's license, good driving record, and reliable vehicle. Travel and an ability to meet persons served in a variety of outreach settings are required. Some flexible hours to accomplish outreach and engagement of enrollees at times when they are reachable; this may involve some early evening hours or later work days. While performing the duties of this job, the employee is frequently required to stand; walk; sit; use hands to finger, handle, or feel; and talk or hear. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception, and ability to adjust focus.