Behavioral Health Care Manager

As an integral member of the care management team the Behavioral Health (BH) Care Manager (CM) will have the opportunity to make a profound impact on the lives of individuals living with complex and/ or chronic Behavioral Health conditions, many of whom also face multiple barriers in their lives which makes it difficult for them to achieve the self-care required to improve their health and well-being. This position requires flexibility and may vary from day-to-day to meet members where they are. Outreach methods may vary based on the needs of the organization and may include telephonic or in person in a variety of potential settings such as but not limited to, the health center, community, home, or an inpatient facility. This role is currently hybrid with potential travel to FQHCs required.

The BH Care Manager is a key member of an interdisciplinary team in the development and implementation of a care plan to enhance the member’s overall health, and to achieve appropriate utilization. They will also assess plans, implement, coordinate, monitor, and evaluate care plans, services, and outcomes to maximize the health of members. This role is currently hybrid in accordance with Mass DOH Covid prevention guidelines. Upon lifted Covid restriction, it may require health center, medical/BH hospital facility, community, or home-based work.

Responsibilities: 

• Conducts Comprehensive Clinical Assessments
• Facilitates medication reconciliation with pharmacist, RN and/or primary care team.
• Engages members and care givers in active care planning with a focus on, medical, behavioral, social, member-centered care needs. Coaches and guides member/representative to meet bio/psycho/social care goals.
• Provide care coordination, which may include but is not limited to facilitating care transitions, supporting the completion of referrals, and/or providing or confirming appropriate follow-up.
• May be required to meet members while they are inpatient to provide education and support about the discharge process and transition the member into care management.t
• Meet members “where they’re at” in other community settings including home or shelters.
• Assess the member’s knowledge of their medical, behavioral health and/or social conditions and provides education and self-management support based on the member’s needs and preferences.
• Connects members with primary care, behavioral health, flexible services, Community Partner, respite, and other community based social services as indicated and appropriate.
• In collaboration with Community Health Workers, create and maintain a comprehensive inventor of local community resources through a web-based application, improving accessibility for Members, providers, and linking members with the appropriate support services.
• Participates in the integrated care team meetings and rounds as required.
• Maintain accurate, timely documentation in electronic systems including health center Electronic Health Records (EHRs)
• Provides coverage for team members who are out of office.
• Other duties as assigned.

Desired Other Skills: 

• Experience within the ACOs member population preferred including Medicare/Medicaid
• Bi/multi-lingual preferred or experience with Language Translation Services
• Familiarity with the MassHealth ACO program
• Familiarity with Federally Qualified Health Centers
• Experience with anti-racism activities, and/or lived experience with racism is highly preferred.

Qualifications: 

• Licensed Clinical Social Worker (LCSW or LICSW), or Licensed Mental Health Counselor (LMHC)
• Master’s Degree in Psychology, Social Work, or related field preferred.
• Minimum 2-5 years of Inpatient or Community Social Work experience providing patient-centered outreach, behavioral health services, needs assessment and support.
• A valid driver’s license and provision of a working vehicle

Community Care Cooperative (C3) is a 501(c)(3) non-profit, Accountable Care Organization (ACO) governed by Federally Qualified Health Centers (FQHCs). Our mission is to leverage the collective strengths of FQHCs to improve the health and wellness of the people we serve. We are a fast- growing organization founded in 2016 with 9 health centers and now serving hundreds of thousands of beneficiaries who receive primary care at health centers and independent practices across Massachusetts. We are an innovative organization developing new partnerships and programs to improve the health of members and communities, and to strengthen our health center partners.

** In compliance with Covid-19 Infection Control practices per Mass.gov recommendations, we require all employees to be vaccinated consistent with applicable law. *