ACO Behavioral Health Case Manager

Fallon Health•Worcester, MA

1d•$82,000 - $92,000

About The Position

Fallon Health is a mission-driven, not-for-profit health care services organization based in Worcester, Massachusetts. The ACO Behavioral Health Case Manager I (BHCM I) is part of an interdisciplinary team focused on transitions of care, assessment and support, care coordination, care management, and improving access to and quality of care for Fallon Health ACO members. The BHCM I is embedded in ACO Partner Provider offices and works closely with partner providers, office staff, care management staff, and other site personnel. The BHCM I establishes telephonic and/or face-to-face relationships with members and caregivers to support ongoing services and coordinate care in line with individualized care plans developed with the member and care team. The role may include in-home or office visits and assessments for members who need face-to-face interaction, coordinating services according to member needs, benefit structures, and available community resources. The BHCM I conducts assessments and makes referrals to Community Partner Programs, including behavioral health and Long-Term Services and Supports, and may refer members to a Flex Program depending on their affiliated ACO. The position may also use an ACD line to support calls and pursue first-call resolution.

Requirements

Master’s degree from an accredited school of social work, mental health counseling, or psychology.
LCSW, or a Master’s MA/MS in Mental Health Counseling under clinical supervision.
Four or more 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.
Ability to conduct behavioral health assessments and develop and implement comprehensive care plans addressing behavioral health needs alongside medical needs and social determinants of health.
Ability to serve on an interdisciplinary care team that may include a member’s primary care physician, medical and behavioral health providers, state agencies, and internal nurse case managers and navigators.
Ability to screen and assist members with social determinants of health, including food, housing, and state applications such as DDS, DYS, DCF, and DMH.
Experience with subpopulations including children, adolescents, people experiencing homelessness, people with SPMI, substance use disorders, and disabilities.
Effective case management, care coordination, and member advocacy skills.
Knowledge of behavioral health community resources, levels of care, and criteria for levels of care.
Familiarity with motivational interviewing and harm reduction to engage and connect with members.
Ability to work collaboratively with a behavioral health vendor.
Familiarity with software systems, including Microsoft Office products such as Excel, Outlook, and Word.

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.

Responsibilities

Conduct telephonic and in-home assessments and develop 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’ 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.