Welcome to Beth Israel Lahey Health Behavioral Services. Our team delivers quality care to clients and families in more than 30 communities throughout the North Shore, Merrimack Valley and Greater Boston. Our mission is to provide personal, compassionate, state-of-the-art, integrated behavioral healthcare that makes a difference in the lives of the people and communities we serve. Our services include mental health counseling, addiction treatment, and family and school-based services.
About the Job
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.
The Clinical Care Manager's Responsibilies are:
- 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.
- 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
- 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
Beth Israel Lahey Health is an integrated system providing patients with better care wherever they are. Care informed by world-class research and education. We are doctors and nurses, technicians and social workers, innovators and educators, and so many others. All with a shared vision for what healthcare can and should be. We are committed to attracting, developing and retaining top talent. We strive to create a diverse and inclusive workplace that reflects the communities in which we work and serve. With a team approach to care, we encourage learning and growth at all levels and offer competitive salaries and benefits.
Equal Opportunity Employer/Minorities/Females/Disabled/Veterans.