ACO Behavioral Health Case Manager

Fallon Health•Worcester, MA

About The Position

The ACO Behavioral Health Case Manager I (BHCM I) is part of an interdisciplinary team supporting transitions of care, care coordination, case management, and access to quality 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 others involved in members’ care. The role establishes telephonic and/or face-to-face relationships with members and caregivers to support ongoing services and coordination consistent with individualized care plans. The position conducts telephonic and in-home or office assessments, coordinates services according to member needs, benefits, and available community resources, and refers members to Community Partner Programs, including behavioral health and Long-Term Services and Supports. Referrals to a Flex Program may also be made where applicable. The BHCM I may 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. It provides coordinated care, including services for people eligible for Medicare and Medicaid, and operates a 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 degree in mental health counseling (MA/MS) 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.
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 primary care physicians, medical and behavioral health providers, state agencies, 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.
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.
Familiarity with Microsoft Office products, including Excel, Outlook, and Word.
Compliance with ACO Partner health and educational requirements.

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 with subpopulations including children, adolescents, people experiencing homelessness, people with severe and persistent mental illness, people with substance use disorders, and people with disabilities.
Ability to work collaboratively with a behavioral health vendor.

Responsibilities

Conduct telephonic and in-home or office assessments and create individualized care plans with members and care teams.
Conduct care transition assessments and maintain knowledge of program benefits and policies.
Educate members and caregivers on 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 where applicable.
Use an ACD line to support department calls and work toward first-call resolution.