Behavioral Health Care Manager-Medicare/Medicaid, Suffolk County / 13-4323 at Medford

Position Description:

The behavioral health care manager will ensure that Network Health beneficiaries receive timely case management across the continuum of care including the following aspects of case management;  assessment of risk and beneficiary needs, care facilitation for continuity of care, care coordination, population health and wellness interventions, and disease management in compliance with regulatory and accreditation requirements and guidelines and Network Health policies and procedures as established by the Integrated Care Management and Quality Management Teams at Network Health. 

The case manager will be responsible for implementing and coordinating beneficiaries’ case management plans of care addressing needs across the continuum and for social and long term support service needs.  The case manager will work with beneficiaries addressing all levels and types of care needs from the intensive care needs of fragile individuals to the management of long-term care needs.  The case manager will work closely with the beneficiary, family/authorized representative and Interdisciplinary Care Team (ICT) to develop a beneficiary-specific care plan to meet the specified goals. 

The case manager will partner with beneficiary and their PCP/Primary Treater to lead the ICT team. (The Case Manager role may be performed by different individuals depending on Beneficiary’s choice, capabilities of team members, and changes in beneficiary’s needs.).

The Case Manager promotes the mission and values of the Clinical Affairs Department, Network Health, and Tufts Health Plan

PRINCIPAL DUTIES AND RESPONSIBILITIES

• Reviews the completed Health Risk Assessment (HRA) with the appropriate Interdisciplinary Care Team (ICT) members and collaboratively develops beneficiary outreach and engagement strategies.
• If “Consent for Release of Information” has not been obtained during the assessment phase,  provides explanation and guidance to beneficiary for signing the “Consent for Release of Information” and attaches the signed consent in the clinical database system allowing access to those Interdisciplinary Care Team (ICT) members the beneficiary provided consent for.  (If the beneficiary does not show readiness to sign the “Consent for Release of Information”, the case manager will continue to work with the beneficiary to address their concerns and obtain consent.)
• Establish and maintain direct contact via in person, telephonic, and other means of electronic communication to follow-up with beneficiary, their primary treater, and appropriate members of the ICT team to address ongoing needs.
• Coordinates services and provides health education and coaching to beneficiaries and their caregivers. Supports and coordinates enhanced self-management training in support of complex clinical conditions.
• Performs and/or coordinates ongoing medication review and reconciliation.
• Leads scheduled case conferences with ICT and is the individual responsible for ensuring agreement by beneficiary and rest of ICT on changes and updates to plan of care. Facilitates the integration of Behavioral Health (BH) and medical primary care services.
• Ensures documentation of case conference outcomes, changes to plans of care, and changes in goals and interventions in the clinical database system.
• Provide ongoing assessment and evaluation of member’s needs (i.e.: medical, BH and social needs).
• Ensures the individualized care plan is developed with input from beneficiary and ICT and mutually agreed by all. Ensures the care plan is person-centered with goals prioritized according to the beneficiary’s stated desire.
• Ensures the individualized care plan is signed by the beneficiary and shared with both beneficiary and ICT via electronic, facsimile transmission, in person, or through the postal service.
• Identify and assist in coordinating services that meet  needs for the beneficiary’s cultural, linguistic, and other restrictions and/or limitations (e.g. vision, hearing,  physical limitations, social isolation, other identified needs)
• Working in conjunction with the beneficiary, primary treater, and appropriate members of the ICT, identify and prioritize problem list, establish goals and interventions, and establish timeframes of meeting stated goals. Provide ongoing identification and document barriers to implementing interventions and achieving goals.  Working with the beneficiary and appropriate ICT members, establish processes to address, reduce, and/or remove barriers.  Identify and document outcomes measures to evaluate the success of meeting goals.
• Work in close collaboration with all ICT members to provide optimal care coordination, ensure appropriate services, and facilitate connection to community resources for beneficiary. Ensures effective communication with ICT by actively involving all in the beneficiary’s care plan.
• Monitors the progress of the care plan as exhibited by the following:
  a. Identifies and documents barriers to goals and/or interventions
  b. Ensures that barriers are identified and documented timely and action steps are incorporated
  c. Identify and documents outcome measures to ensure goals are fully met
  d. Initiate revision/modification of care plan as needed according to beneficiary needs
• Provides re-assessment of the plan of care at a minimum quarterly and annually to evaluate the beneficiary’s ongoing needs and provide updates to the plan of care if change in care needs are identified and agreed upon by the beneficiary and the ICT.
• Performs  evidenced-based inpatient admissions, skilled facility admissions, continued stays, specialty referrals and specific ancillary services for  LOS, medical necessity, discharge planning and care coordination to ensure appropriate services is provided.
• Participate with on-call coverage for beneficiary and/or provider needs during after-hours and weekend coverage.
• Attends departmental, interdisciplinary care team, and organizational meetings as required to represent the Care Management department.
• Maintain professional growth and development through self-directed learning activities and involvement in professional, civic, and community organizations.
• Maintain an active Massachusetts profession-specific license in good standing without restrictions.
• Perform related duties as assigned.
  

Qualifications:

• RN, Masters in Nursing, Psychology or Social Work or Doctorate in Psychology; CCM preferred
• Skill in assessing, planning, and managing patient care as acquired through three years of clinical nursing experience in an acute care hospital; rehabilitation or home care experience.
• Working knowledge of Medicare and Medicaid programs and experience with regulatory compliance and reporting requirements.
• Working knowledge of the DSM-IV-R required.
• Familiarity with health plan case management, care management, and community outreach activities.
• Advanced communication and interpersonal skills with all levels of internal and external customers.
• Demonstrated experience working in a Microsoft® (or similar) Office Environment with the following or similar applications; Word, Excel, Outlook
• Experience with McKesson’s Care Enhance Clinical Management Software (CCMS®) and McKesson’s InterQual® Clinical Screening Criteria a plus.
• Experience using Clinical Screening Criteria required.
• Strong organizational and communication skills
• Must have valid driver’s license with appropriate automobile insurance coverage to fulfill principal duties of position.
• Extensive travel within Massachusetts is required.
• RN, LICSW, LMHC, LMFT, Clinical Nurse Specialist, or Licensed Psychologist

Country: USA, State: Massachusetts, City: Medford, Company: Network Health.