Pop Health & C3 Behavioral Healthcare Coordin

South Florida Community Care Network•Sunrise, FL

20h•Hybrid

About The Position

The Behavioral Health Care Coordinator is a core member of a collaborative care team, working with enrollees’ medical providers, mental health teams, and the Concierge Care Coordination team. The role coordinates and supports the mental and physical health care of members in an assigned behavioral health caseload across all lines of business, including managed care programs serving adults and children with severe mental illness. The coordinator supports care across the continuum, from complex medical conditions and chronic disease management to preventive care. The role helps members receive care at the safest and most appropriate level, addresses immediate care gaps, and supports members in managing chronic conditions. Working alongside practitioners and following established care plans, the coordinator uses cost-effective, evidence-based guidelines to address acute needs, reduce complications and morbidity, improve health outcomes, and lower healthcare costs. Work is performed in accordance with applicable Medicaid and Florida Healthy Kids contracts, Community Care Plan policies and procedures, and Patient-Centered Medical Home standards. The position follows a hybrid work schedule that may change according to company needs. Duties include work inside and outside the office and travel to other offices and domestically. The role requires a Florida Level 2 background screening through the Florida Care Provider Background Screening Clearinghouse.

Requirements

Bachelor’s degree in Nursing (BSN), or a Master’s degree in Social Work (MSW) and Licensed Clinical Social Worker (LCSW) qualification.
For candidates with a nursing degree, a current, unrestricted Registered Nurse (RN) license in Florida is required.
For candidates with a social work degree, a current, unrestricted Licensed Clinical Social Worker (LCSW) license is required.
At least three years of clinical experience in behavioral health, mental health, substance use, care management, or a related behavioral or mental healthcare setting.
Effective clinical assessment and critical-thinking skills to identify behavioral health, medical, psychosocial, and care coordination needs and appropriate interventions.
Ability to assess and coordinate behavioral health, substance use, medical, psychosocial, functional, and social needs across varying levels of acuity and complexity.
Care management and care-planning skills, including developing, implementing, monitoring, and updating individualized member-centered care plans.
Ability to coordinate care and communicate effectively across providers, hospitals, substance use treatment providers, community resources, and multidisciplinary care teams.
Member engagement, education, and communication skills, including explaining healthcare information clearly and supportively.
Sound clinical judgment, problem-solving, and decision-making skills, including recognizing risks, changes in condition, crisis needs, and concerns requiring escalation.
Excellent written, verbal, interpersonal, and clinical documentation skills.
Organizational and time-management skills, including the ability to manage a caseload, prioritize by acuity and risk, and balance competing priorities.
Attention to detail and ability to maintain accurate, timely documentation in accordance with departmental, contractual, regulatory, and accreditation requirements.
Ability to work independently and collaborate effectively with leadership, multidisciplinary teams, providers, and internal and external stakeholders.
Proficiency with Microsoft Office applications and electronic health record or care management systems.

Nice To Haves

Certified Case Manager (CCM).
Psychiatric-Mental Health Nursing Certification (PMH-BC), Certified Addictions Registered Nurse (CARN), or another applicable behavioral health certification, as appropriate to discipline.
Experience in care management, case management, care coordination, population health, or a managed care or health plan setting.
Experience coordinating behavioral health, medical, and social needs across multidisciplinary providers and healthcare settings.
Knowledge of Medicaid, managed care, behavioral health services, and applicable healthcare regulatory and accreditation requirements.

Responsibilities

Conduct comprehensive assessments of behavioral health, medical, substance use, psychosocial, functional, social, and other needs, including barriers, risk factors, and support needs.
Develop, maintain, review, and update individualized, member-centered care plans with members, families or caregivers, providers, and the multidisciplinary care team as appropriate.
Set measurable goals and interventions based on identified needs, member priorities, and the established plan of care.
Identify care gaps and barriers to treatment and coordinate appropriate interventions and follow-up.
Provide ongoing care management and clinical follow-up based on member needs, risk, acuity, and program requirements.
Monitor behavioral and medical status, treatment plans, medications, utilization, services, and other factors affecting members’ health and care needs.
Review clinical information and healthcare utilization to identify changes in condition, emerging needs, care gaps, and opportunities for intervention.
Coordinate timely follow-up after hospitalizations, emergency department visits, crisis events, and other significant changes in health status or care needs.
Address barriers to treatment, medication adherence, appointments, preventive care, behavioral health services, substance use treatment, and other identified healthcare needs.
Conduct outreach to members with patterns of emergency department visits, hospitalizations, or other utilization concerns and support appropriate interventions.
Escalate significant behavioral health or clinical concerns to appropriate clinical leadership or the Medical Director.
Coordinate communication and continuity of care among members, families or caregivers, behavioral health and primary care providers, specialists, hospitals, substance use treatment providers, community resources, and other care-team members.
Support safe transitions following hospitalization, crisis stabilization, changes in level of care, or transitions between healthcare settings and services.
Educate and support members regarding care plans, services and resources, treatment adherence, self-management, and other healthcare needs.
Use appropriate engagement and evidence-based behavioral health techniques within professional scope and departmental guidelines.
Participate in or facilitate multidisciplinary care conferences when indicated and collaborate with internal and external stakeholders.
Identify psychosocial and social barriers and coordinate referrals to appropriate internal or community resources.
Conduct or participate in home or community-based assessments when required or indicated by program or contractual requirements.
Maintain complete, accurate, and timely documentation of assessments, care plans, interventions, interactions, provider coordination, and care management activities.
Complete required documentation, reporting, and care management activities within established timeframes and applicable contractual, regulatory, accreditation, and departmental requirements.
Identify documentation gaps or discrepancies and maintain supporting information for program, audit, or accreditation review.
Protect member confidentiality and health information in accordance with HIPAA and organizational requirements.
Participate in case reviews, multidisciplinary discussions, training, quality improvement activities, and other behavioral health program initiatives.
Identify recurring member, provider, service, or operational barriers and communicate concerns and improvement opportunities to departmental leadership.
Perform other job-related duties assigned by a supervisor or management.