Fallon Health

  • Manager Behavioral Health (NaviCare) ---- Growing team and company at Fallon Health!

    Location US-MA-Worcester
    Posted Date 2 months ago(4/12/2018 1:58 PM)
    Job ID
    # Positions
  • Overview

    About Fallon Health:

    Founded in 1977, Fallon Health is a leading health care services organization that supports the diverse and changing needs of those we serve. In addition to offering innovative health insurance solutions and a variety of Medicaid and Medicare products, we excel in creating unique health care programs and services that provide coordinated, integrated care for seniors and individuals with complex health needs. Fallon has consistently ranked among the nation’s top health plans, and is accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit www.fallonhealth.org.


    About NaviCare:

    Fallon Health is a leader in providing senior care solutions such as NaviCare, a Medicare Advantage Special Needs Plan and Senior Care Options program. Navicare integrates care for adults age 65 and older who are dually eligible for both Medicare and MassHealth Standard. A personalized primary care team manages and coordinates the NaviCare member’s health care by working with each member, the member’s family and health care providers to ensure the best possible outcomes.


    Position Overview: 

    The NaviCare Behavioral Health Manager is responsible for:    

    • Managing a multidisciplinary team to ensure timely coordination of quality healthcare services for NaviCare members with varying levels of conditions, including, but not limited to, oversight of reporting, process improvement, and program development
    • Ensuring team performance goals are met and ensuring program staff are trained and compliant with departmental and policy requirements
    • Educating NaviCare Clinical Team members on various levels of behavioral health interventions and recommending and supporting team actions to ensure effective member care plan development and implementation
    • Provide leadership and supervision and support for behavioral health case managers fostering integration of behavioral health within care teams and member care plans
    • Partnership with State Agencies such as Department of Mental Health and other Agencies and mental health providers fostering collaborative working relationships
    • Developing and implementing quality improvement projects and strategies to support the Program in meeting quality and performance measures including, but not limited to, HEDIS, Medicare Five Star, External Quality Review projects, etc.



    Team Management: 

    • Hires, orients, supervises, evaluates, counsels and terminates staff that function within the assigned Team
    • Provides education to the Team on the Model of Care, policies, procedures, workflows, and best practices to manage member care
    • Oversees performance of Team ensuring Program and Team goals are met utilizing reports and facilitating team independent use of such
    • Establishes Team member productivity and professional goals in conjunction with the Program Leadership Team
    • Evaluates staff performance based on these defined goals and implements coaching and performance improvement measures and actions when necessary
    • Recommends, develops, and works with NaviCare Clinical Reporting Team and TruCare I.T. Development team to ensure case management documentation system effective to meet Program needs
    • Develops workflows and educates Team on workflows as appropriate
    • Monitors Team adherence to established workflows and implements improvements and workflow modifications as required
    • Meets 1:1 with Direct Reports at least monthly and more frequently based upon need and utilizes established reports and systems to track and ensure performance to Team member and Program goals
    • Audits Team member documentation for accuracy, timeliness, appropriateness, and adherence to workflow
    • Performs and/or ensures Team performs quality and inter-rater reliability audits on a regular basis to assure compliance with the Program’s policies and procedures
    • Ensures staff utilize an effective communication style and methods to engage members/personal representatives in care management


    Program Leadership Activities:


    • Leads, participates in, and implements quality improvement projects
    • Promotes full integration of behavioral health into overall processes and procedures designed to provide member centered care plans
    • Works collaboratively with leadership team on overall program goals processes and procedures
    • Ensures team members follow workflow and reporting requirements to support projects and outcome requirements of programs including but not limited to Transition of Care and Emergency Room utilization
    • Responsible for development and implementation of care transition protocols for Program membership
    • Documents and presents Quality Improvement Projects to regulatory agencies including but not limited to Center for Medicare and Medicaid Services (CMS), External Quality Review Organizations (EQRO), and other accrediting and regulatory oversight agents
    • Develops, generates, and or utilizes reports produced by the Data Specialist and Program Support Team to ensure Team performance to goal
    • Utilizes reporting software to generate process measure reports for team performance oversight and teaches team members to be proficient utilizing reporting software to produce their own reports
    • Recommends modifications to the Model of Care and participates in activities associated with cost of care projects, and other initiatives associated with Program financial improvement


    Provider/Vendor Management and Coordination: 


    • Collaborates with vendors/providers such as the Aging Service Access Point Staff and Long Term Care Facility Staff to ensure the NaviCare Member care needs are met
    • Leads vendor relationship(s) with contracted providers to ensure an effective and positive relationship between organizations
    • Supports Program efforts to embed team members in provider locations and works to ensure team members communicate effectively with provider partners
    • Participates as the “Clinical Team Subject Matter Expert” in Provider Orientations and/or Refreshers in collaboration with Provider Relations and Outreach teams


    Program Oversight (as assigned):

    • Updates policies and processes and ensure processes meet regulatory/contract and efficiency requirements
    • Trains staff on policies/processes and Resource Library use
    • Develops and updates new hire training program and ensures staff are trained and proficient throughout their employment tenure
    • Works with Medical Director/Senior Director/designee to identify best practices for management of members and works with Medical Director/Senior Director/designee to identify and then implement workflow and process changes
    • Evaluates staffing and operational needs to ensure that the day-to-day operations of the Team are carried out in compliance with departmental and health plan budgetary requirements and works with Senior Director/designee and peers to readjust staffing for teams based upon census need


    Member Related Oversight (as assigned):

    • Facilitates and/or conducts Team huddles up to three times per week – Team huddle content includes but is not limited to members experiencing a care transition and proactive brainstorming and planning to modify member care plans – involves clinical resources as appropriate
    • Ensures department team members work collaboratively with members of the Fallon Health Utilization Management Department
    • In conjunction with Medical Director/Senior Director/designee facilitates the Team with discharge planning for Program member situations as applicable
    • In conjunction with Medical Director/Senior Director/designee, ensures the NaviCare members have an effective care plan to meet the member’s needs
    • In conjunction with Medical Director/Senior Director/designee, ensures staff modify member care plans based upon member need working to creatively and effectively implement plans that have positive outcomes for the member and the Plan



    • Works collaboratively and cohesively with all members of the care team (both internal and external staff and providers)
    • Maintains an ongoing awareness of clinical, social, and financial resources available in the community
    • Supports department colleagues, covering and assuming changes in assignment as assigned by Senior Director/designee
    • Strictly observes HIPAA regulations and the Fallon Health policies regarding confidentiality of member information
    • Performs other responsibilities as assigned by the Senior Director/designee



    Education: Graduate from an accredited school of social/behavioral health mandatory. Advanced degree in social work/mental health field required

    License:  Active, unrestricted license as a Licensed Mental Health Clinician; OR Licensed Mental Health Family Therapist,; OR Licensed Independent Clinical Social Worker; AND current Driver’s license

    Certification: Certification in Case Management a plus

    Resources: Microsoft products (Word, Excel, Visio, Powerpoint, Outlook); reporting software such as Business Objects; Boxer Application; CaseNET TruCare System; QNXT System



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



    • A minimum of five years clinical experience as a licensed clinician managing/coordinating/facilitating/providing care for elders over the age of 65 required
    • Two years of supervisory or management experience in a health care setting; preferably with experience supervising/managing a mix of clinical and non-clinical staff required
    • Experience working in a healthcare setting as a member of a professional team coordinating care for adult populations who are diagnosed with health conditions or chronic disease, including mental illness of substance use disorders required
    • Familiarity with in home services both skilled and non-skilled, outpatient services including medical and behavioral health, knowledge of different levels of care including but not limited to acute, rehab, long term, and experience with Medicare and Medicaid coverage criteria and requirements required
    • Three years’ experience performing care coordination in a managed care setting preferred
    • Experience developing policies, procedures, and workflows preferred
    • Experience with performance improvement projects including but not limited to establishing criteria for report queries, utilizing objective data to improve processes, and implementation of projects preferred
    • Experience with improvement methodologies including but not limited to lean and six sigma a plus


    Physical Requirements of Role:

    Usual office environment with frequent sitting, walking, standing, and occasional climbing, stooping, kneeling, crawling and balancing. Frequent use of eye, hand and finger coordination enabling the use of office machinery. Oral and auditory capacity enabling interpersonal communication as well as communication through automated devices such as the telephone. Activity is frequent, at least 2/3 of the time.


    In addition, this role requires independent driving capability and the ability to perform in home visits to members and/or providers/facilities. Activity is occasional – activity exists less than 1/3 of the time.








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