ACO Behavioral Health Case Manager ll

Fallon Health • Worcester, MA

7d

About The Position

The ACO Behavioral Health Case Manager II (BHCM II) is an integral member of an interdisciplinary team focused on transition-of-care assessment and support, care coordination, care management, and improving access to and quality of care for Fallon Health ACO members. The BHCM II works from ACO Partner Provider Offices and collaborates with ACO Partner Providers, office staff, care management staff, and others involved in members’ care. The role establishes telephonic and/or face-to-face relationships with members and caregivers to support ongoing services and care coordination consistent with individualized care plans developed with members and the care team. The position may include in-home or office visits and assessments for members who need face-to-face interaction, with the goal of coordinating services according to benefit structures and available community resources. The BHCM II conducts assessments and refers members to Community Partner Programs, including Behavioral Health and Long-Term Services and Supports, and may make referrals to a Flex Program depending on the member’s ACO. The role may also use an ACD line to support incoming and outgoing calls and seek first-call resolution.

Fallon Health is a mission-driven, not-for-profit health care services organization based in Worcester, Massachusetts. The organization provides coordinated, integrated care, with a special focus on people who qualify for Medicare and Medicaid, and also provides care through its Program of All-Inclusive Care for the Elderly (PACE).

Requirements

• Master’s degree from an accredited school of social work, mental health counseling, or psychology.
• LCSW or a master’s-level mental health counseling credential (MA/MS) under clinical supervision.
• At least four years of clinical experience in a behavioral health or mental health setting.
• Satisfactory Criminal Offender Record Information (CORI) results.
• Compliance with ACO Partner Health and Educational requirements.
• Strong case management, care coordination, and member advocacy skills.
• Knowledge of behavioral health resources, levels of care, and criteria.
• Familiarity with motivational interviewing, harm reduction, and culturally sensitive engagement.
• Ability to collaborate effectively with interdisciplinary teams, including providers, state agencies, and behavioral health vendors.
• Proficiency in Microsoft Office (Excel, Outlook, and Word) and EMR systems.

Nice To Haves

• Certification in Case Management.
• Experience with government programs, community resources, case management, substance use disorders, and/or severe and persistent mental illness.
• Experience working with diverse populations, including children, adolescents, people experiencing homelessness, people with SPMI, substance use disorders, and disabilities.

Responsibilities

• Conduct telephonic and in-home assessments and create individualized care plans with members and care teams.
• Perform care transition assessments and maintain knowledge of program benefits and policies.
• Educate members and caregivers about disease management and self-care.
• Advocate for members seeking access to benefits and community resources, including housing, food, and transportation.
• Develop member-centered care plans and monitor progress toward goals.
• Coordinate with Nurse Case Managers, Navigators, Social Care Managers, and community partners.
• Build relationships with members, families, and providers to support timely, cost-effective care.
• Participate in clinical rounds and report safety concerns to Protective Services as needed.
• Attend care plan meetings and provider visits, and lead reviews when applicable.
• Complete assessments, notes, and care plans in TruCare and EMR systems.
• Serve as a behavioral health consultant and provide training as needed.
• Collaborate with Fallon Health, Beacon Health Options, and contracted providers to ensure timely mental health and substance use supports.
• Maintain HIPAA compliance and attend required meetings and supervision.
• Support quality initiatives and department projects.
• Cover assignments as needed and perform other duties as directed.
• Refer members to Community Partner Programs, including Behavioral Health and Long-Term Services and Supports, and to a Flex Program when applicable.
• Use an ACD line as needed to support department calls and seek first-call resolution.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level