The Care Manager oversees the delivery of care coordination and management services provided by Care Coordinators and Community Health Workers on the BH CP team to which they are assigned. The Care Manager further delivers care coordination services for enrollees. This individual works under the direction of the Behavioral Health Community Partner (BH CP) Program Director. Care Managers may have expertise in Social Work or Nursing and will work together to meet the holistic, person-centered needs of enrollees.
The Care Manager ensures staff compliance with BH CP contract requirements primarily to include BH CP Care Coordinators and Community Health Workers. The Care Manager ensures that enrollees are engaged in BH CP program activities through the Care Coordinators and Community Health Workers and through their own efforts to deliver fully integrated, coordinated care management services.
Essential Job Functions
- Supervise Care Coordinators and Community Health Workers to execute workflow processes, including but not limited to, staff efforts to: obtain signatures on enrollee Consent forms to participate in the BH CP program; obtain signatures on BH CP Participation Forms; administer Comprehensive Assessments of person-centered enrollee needs. The Care Manager further oversees the creation and implementation of Interdisciplinary Care Teams (ICTs), the creation of Person-Centered Treatment Plans (PCTPs), and manages and performs tracking and follow-up of assignments and workflow for Care Coordinators and Community Health Workers and for any enrollees for whom they are delivering care management services as assigned.
- Collaborate with Care Coordinators and Community Health Workers to:
- Identify and resolve barriers that prevent the enrollee from meeting goals as documented in the PCTP.
- Augment, finalize and approve comprehensive assessments as required by EOHHS.
- Assess progress against the PCTP goals and modify as needed based on enrollee strengths, needs, and preferences. Reassess and update the PCTP as per contract requirements.
- Develop and implement strategies to support safe transitions in care for enrollees moving between care settings.
- Assist enrollees in obtaining transportation to needed appointments for assigned caseload and/or in collaboration with Care Coordinators and Community Health Workers.
- Maintain enrollee records, completing all necessary paperwork in a timely manner.
- Facilitate small groups with members.
- Maintain a partial BH CP caseload, in addition to BH CP supervisory responsibilities.
- Assist in training Care Coordinators and Community Health Workers to deliver efficient and effective BH CP program services in collaboration with Brien Center leadership, referral agencies, ACO/MCO’s, and other care providers eliminating duplication of effort where possible.
- Other duties as assigned by supervisor.
- Support and maintain the principles and policies of the agency and BCHP Program.
- Attend meetings as scheduled or requested.
- Flexibly respond to program scheduling needs
- Communicate a sense of hopefulness and respect for enrollee rights and for colleagues
- Represent the agency in a professional manner in all community contacts
- Demonstrate a commitment to the agency’s mission and values.
- Driver’s license checks (RMV).
- Criminal Offender Record Information Check (CORI).
For Registered Nurses only: Conduct medication reconciliations for enrollees as needed within three days of discharge from a hospitalization.
- Credentials may include:
- LCSW, LICSW, LMHC, LMFT or LADC I preferred with requirement to obtain highest level of licensure within 6 months of eligibility date; OR
- Master’s degree in social work, psychology, counseling or other clinical concentration required
- Registered Nurse
- Diagnostic and treatment knowledge of behavioral health and medical conditions.
- Demonstrated ability to supervise staff in an outreach-based job with significant focus on productivity
- Demonstrated ability to offer leadership to, and work with, an interdisciplinary team
- Experience providing person-centered care coordination and care management to adults with mental illness and substance use disorders as well as chronic co-morbid medical conditions
- Experience with accessing local resources, navigating health, behavioral health, and substance abuse treatment systems, as well as a strong familiarity with community-based resources and services.
- Managerial experience overseeing clinical and non-clinical staff preferred
- Valid driver’s license with a reliable, properly insured vehicle required.
- Positive, collaborative attitude particularly with regard to staff management and fluid participation in team roles
- Excellent supervisory skills including ability to perform or manage communications, documentation, time management and organizational needs
- Leadership ability
- Excellent staff management capabilities including efforts to train, motivate and support staff to meet program goals
- Proficient computer skills and knowledge of EHR systems
- Works in office; Works in various locations through out the community to best meet the needs of enrollees
- Manual and visual dexterity; correctable
- Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential job functions