Job Description

Job Profile Summary

The Complex Care Manager works with relevant stakeholders to identify and engage clients in intensive clinical care management with a focus on successfully addressing client’s behavioral health and social determinants of health, improving patient experience, advancing health and reducing cost. The services focus on high risk and complex clients who have a pattern of inpatient admissions, high utilization of emergency services, difficulty engaging with outpatient treatment and may also be medically complex. The role requires assertive outreach, advocacy, service coordination, monitoring, follow up and general assistance to help clients manage barriers that may impede access to clinical services and progress in their recovery. This position supports clients across Boston and will require in-person visits to members in the community. Excellent interpersonal skills, patient engagement skills and the ability to work independently and collaboratively are key requirements of the job. Clinical experience working with behavioral health conditions prevalent within the Medicaid population including psychotic disorders, personality disorders, and substance use disorders is necessary. Care managers collaborate closely with providers throughout the health system including outpatient therapists, psychiatrists, pharmacists, and PCPs as well as develop partnerships with other community resources.

• Job Description

Job Description

POSITION SUMMARY:

The Complex Care Manager works with relevant stakeholders to identify and engage clients in intensive clinical care management with a focus on successfully addressing client’s behavioral health and social determinants of health, improving patient experience, advancing health and reducing cost. The services focus on high risk and complex clients who have a pattern of inpatient admissions, high utilization of emergency services, difficulty engaging with outpatient treatment and may also be medically complex. The role requires assertive outreach, advocacy, service coordination, monitoring, follow up and general assistance to help clients manage barriers that may impede access to clinical services and progress in their recovery. This position supports clients across Boston and will require in-person visits to members in the community. Excellent interpersonal skills, patient engagement skills and the ability to work independently and collaboratively are key requirements of the job. Clinical experience working with behavioral health conditions prevalent within the Medicaid population including psychotic disorders, personality disorders, and substance use disorders is necessary. Care managers collaborate closely with providers throughout the health system including outpatient therapists, psychiatrists, pharmacists, and PCPs as well as develop partnerships with other community resources.

ESSENTIAL RESPONSIBILITIES / DUTIES:

• Identify and engage appropriate clients for complex care management from lists and referrals, in collaboration with supervisor and other program leads.
• Ability to execute core care management duties:
  • Comprehensive assessment: bio-psycho-social-spiritual
  • Collaboration with client and care team to develop client-centered care plan
  • Refer clients to all necessary services including, but not limited to, medical treatment, behavioral health/substance use treatment, financial assistance, child-care, housing, food, clothing, vocational services, and transportation
  • Provide consistent outreach and support services to enable clients to utilize clinical treatment
  • Monitor clients utilization of care across the care continuum, including Emergency Department Visits and inpatient admissions
  • Collaborate with community partners, such as medical providers, substance use disorder/mental health service providers, and social service agencies;
  • Assessment of goal completion, with transition of client to ongoing supports upon graduation from program
• Provide mobile care management in the community to meet client’s needs including participating in off-site discharge planning meetings, and visiting clients at local programs, shelters or their homes if indicated
• Facilitates interdisciplinary consultation on client’s behalf through participation in team meetings, clinical reviews, and collaboration with client’s providers.
• Independently address client’s behavioral health crises by completing risk assessments, referring to appropriate levels of care, developing crisis treatment plans, and consulting with program manager when clinically indicated.
• Develop working relationships with collateral resources and other community service providers
• Participate in all training requirements and opportunities as designated by program manager
• Actively participate in growth and development of program
• Take lead on clinical needs of program caseload in absence of program manager and when indicated
• Complies with established metrics for performance and adheres to documentation and work flow standards including clearly documenting all progress and submitting accurate billing within expected time frames
• Utilizes the electronic health record and other IT interfaces as necessary to track and monitor patients
• Maintains HIPAA standards and confidentiality of protected health information.
• Adheres to departmental/organizational policies and procedures.

Must adhere to all of BMC’s RESPECT behavioral standards.

(The above statements in this job description are intended to depict the general nature and level of work assigned to the employee(s) in this job.  The above is not intended to represent an exhaustive list of accountable duties and responsibilities required).

JOB REQUIREMENTS

EDUCATION:

Master’s Degree in Social Work or Counseling

CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED :

None

EXPERIENCE:

Experience providing case management services

Experience working with vulnerable patient populations

Experience working with clients with serious mental illness and/or substance use disorders

KNOWLEDGE AND SKILLS:

• Strong understanding and familiarity with common diagnoses across behavioral health and medical settings
• Strong understanding and familiarity with levels of care and how to navigate behavioral health system
• Extensive knowledge of healthcare systems and relevant community resources
• Sensitivity to ethnic, cultural, gender, and sexual orientation diversity, values, beliefs, and behaviors
• Excellent interpersonal skills and ability to work collaboratively
• Self-management skills, including ability to prioritize and set patient-centered goals
• Excellent written and verbal communication
• Able to maintain professional boundaries
• Ability to work with diverse, safety-net population
• Skilled at engaging difficult to engage patients—build rapport, trust
• Ability to work in a fast paced environment, inclusive of organizational skills, time management skills, critical thinking, and problem solving abilities
• Computer competency, inclusive of the ability to access and enter data through the electronic medical record system, submit billing, assist clients with scanning/faxing/printing and manage personal email system
• Bilingual or multi-lingual skills (beyond that of English) appropriate to the patient population serviced, is preferred

Equal Opportunity Employer/Disabled/Veterans

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