ACO Behavioral Health Case Manager

About Fallon Health:

Fallon Health is a mission-driven not-for-profit health care services organization based in Worcester, Massachusetts. For 45 years we have been improving health and inspiring hope in the communities we serve. Committed to caring for those who need us most, we pride ourselves on providing equitable access to coordinated, integrated care for our members with a special focus on those who qualify for Medicare and Medicaid. We also serve as a provider of care through our Program of All-Inclusive Care for the Elderly (PACE). Dedicated to delivering high quality health care, we are continually rated among the nation's top health plans for member experience and service and clinical quality.

Brief Summary of Purpose:

The Accountable Care Organization (ACO) Behavioral Health Case Manager (BHCM) is an integral part on 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 embeds in the ACO Partner Provider Offices and works closely with ACO Partner Providers, Office Staff, Care Management Staff and others at the Partner sites managing member care.

BHCM seeks to establish telephonic and/or face to face relationships with the member/caregiver(s) to better ensure ongoing service provision and care coordination, consistent with the member specific care plan developed by the BHCM and Care Team.

Responsibilities may include conducting in home/office face to face visits for member identified as needing face to face visit interaction and assessments with the goal to coordinate and facilitate services to meet member needs according to benefit structures and available community resources. The BHCM conducts assessments and refers members to Community Partner Programs such as Behavioral Health and Long-Term Services and Supports. The BHCM may also refer members to Flex Program as applicable depending upon the ACO the member is affiliated with. The BHCM may utilize an ACD line to support department and incoming/outgoing calls with the goal of first call resolution with each interaction.

Responsibilities include:

Member Assessment, Education, and Advocacy

Telephonically assesses and case manages a member panel
• May conduct in home face to face visits for onboarding new enrollees and reassessing members, utilizing a variety of interviewing techniques, including motivational interviewing, and employs culturally sensitive strategies to assess a Member's clinical/functional status to identify ongoing special conditions and develops and implements an individualized, coordinated care plan, in collaboration with the member, the Clinical Integration team, and Primary Care Providers, Specialist and other community partners, to ensure a cost effective quality outcome
• Performs Care Transitions Assessments - per Program and product line processes
• Maintains up to date knowledge of Program and product line benefits, Plan Handbook Benefits and Coverage details, and department policies and processes and follows policies and processes as outlined to be able to provide education to members and providers; performing a member advocacy and education role including but not limited to member rights
• Serves as an advocate for members to ensure they receive Fallon Health benefits as appropriate and if member needs are identified but not covered by Fallon Health, works with community agencies to facilitate access to programs such as community transportation, food programs, and other services available through senior centers and other external partners
• Follows department and regulatory standards to authorize and coordinate healthcare services ensuring timeliness in compliance with documented care plan goals and objectives
• Assesses the Member's knowledge about the management of current disease processes and medication regimen, provides teaching to
• increase Member/caregiver knowledge, and works with the members to assist with learning how to self-manage his or her health needs, social needs or behavioral health needs
• Collaborates with appropriate team members to ensure health education/disease management information is provided as identified
• Collaborates with the interdisciplinary team in identifying and addressing high risk members
• Ensures members/PRAs participate in the development and approval of their care plans in conjunction with the interdisciplinary primary care team
• Strictly observes HIPAA regulations and the Fallon Health Policies regarding confidentiality of member information
• Supports Quality and Ad-Hoc campaigns

Care Coordination and Collaboration

• Provides culturally appropriate care coordination, i.e., works with interpreters, provides communication approved documents in the appropriate language, and demonstrates culturally appropriate behavior when working with member, family, caregivers, and/or authorized representatives
• With member/authorized representative(s) collaboration develops member centered care plans by identifying member care needs while completing program assessments and working with the member to approve their care plan
• Manages ACO members in conjunction with the Nurse Case Manager, Navigator, Social Care Managers, ACO Partners, Community Partners, Behavioral Health Partners and others involved/authorized in the member's care
• Monitors progression of member goals and care plan goals, provides feedback and works collaboratively with care team members and work effectively in a team model approach to coordinate a continuum of care consistent with the Member's health care goals and needs
• Works collaboratively with Fallon Health Pharmacist, referring members in need of medication review based upon Program process
• Develops and fosters relationships with members, family, caregivers, PRAs, vendors and providers to ensure good collaboration and coordination by streamlining the focus of the Member's healthcare needs utilizing the most optimal treatment approach, promoting timely provision of care, enhancing quality of life, and promoting cost-effectiveness of care
• Actively participates in clinical rounds
• Ensures timely filing with the appropriate Protective Services agency regarding any concerns about the safety and well being of a member
• Maintains an ongoing awareness of community clinical, psychiatric, and other outpatient resources as well as state and federal resources as needed

Provider Partnerships and Collaboration

• May attend in person member/provider visits, care plan meetings with providers and office staff and may lead care plan review with providers and care team as applicable
• Demonstrates positive customer service actions and takes responsibility to ensure member and provider requests and needs are met

Regulatory Requirements - Actions and Oversight

• Completes Program Assessments, Notes, Screenings, and Care Plans in the TruCare and Provider EMR systems according to Program policies and processes

Provides training and consultation

• Serves as a behavioral health consultant to the Fallon Health Clinical Integration Team
• Offers recommendations to continued program development and is an active participant in suggesting opportunities to enhance the program
• Works with Fallon Health Provider Relations and Beacon Health Options to ensure that contracted behavioral health providers are knowledgable about the plan benefits, eligibility requirements, and care coordination and communication needs
• Coordinate with Beacon staff to ensure quality and timely arrangement of necessary mental health and substance use supports.
• Attends Fallon Health/Beacon meetings when requested
• Attends supervision and 1:1 meetings with Leader. Attends Team Huddles, staff meetings, site meetings and other Fallon Health and business related meetings as required. Meetings may be in person or telephonic depending upon the need

Other

• Performs other responsibilities as assigned by the Manager/designee
• Supports department colleagues, covering and assuming changes in assignment as assigned by Manager/designee

Education

Master's degree from an accredited school of social work, mental health counseling, psychology, or human services required.

License: Active, unrestricted license as a LCSW, LICSW or LMHC; reliable transportation

Certification: Certification in Case Management a plus

Other: Satisfactory Criminal Offender Record Information (CORI) results.

This role requires compliance with the ACO Partner Health and Educational requirements.

Performance Requirements including but not limited to:

• Ability to conduct behavioral health assessments, develop and implement comprehensive care plans that addresses the member's behavioral health needs in conjunction with their medical needs and social determinants of health
• Ability to serve as a member on an interdisciplinary care team that may include the member's primary care physician, medical providers, behavioral health providers, state agencies and/or internal nurse case managers and navigators
• Ability to screen and assist members with social determinants of health including but not limited to relevant food, housing and state applications (e.g., DDS, DYS, DCF, DMH)
• Experience with subpopulations including children, adolescents, the homeless, those with SPMI, substance use disorders, and disabilities
• Effective case management, care coordination, and member advocacy skills
• Knowledge about 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 BH vendor
• Familiarity with software systems including but not limited to Microsoft Office Products - Excel, Outlook, and Word