Fallon Health

  • Behavioral Health Case Manager

    Location US-MA-Worcester
    Posted Date 7 days ago(7 days ago)
    Job ID
    # Positions
    Behavioral Health
  • 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 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.


    Brief summary of purpose:


    Responsible for assessing an enrollee’s mental health status and developing a plan to coordinate a continuum of care consistent with the enrollee’s mental health needs and goals. Serves as an active participant on the patient care team (PCT) and an advocate for the enrollee for all behavioral health needs. The BHC is actively involved in with the enrollee from time of psychiatric admission through discharge and ensures all PCT members and healthcare provides are aware of enrollee’s status. Facilitates prompt access to outpatient mental health supports consistent with appropriate clinical guidelines. Regularly coordinates mental health benefits and coordinates supports, consultations, or care planning with Beacon Health Strategies representatives. The BHC also assesses the need for and coordinates further evaluation or treatment.



    Assessment and care plan coordination 

    • Contacts Enrollees and Caregivers/guardians telephonically and/or in person after receiving a BH referral/notification form and on an ongoing basis to:
      •   Conduct psychiatric assessment and administer the PHQ9,MMSE,CAGE or other assessment tools as indicated;
      •   Assess the mental health needs of the Enrollees;
      •   Recommend modifications to the Behavioral Health plan.
    • Completes a homevisit for all agreeable referred Enrollees within 10 business days of referral, at any time of emergent mental health need or indicated behavioral health clinical change (not otherwise accounted for by a medical change) to assign a rating category which determines BH case management level of involvement.
    • Completes emergent home visits with an Enrollee to assess reported suicidal/homicidal statements, plans emergent mental helath supports using Section 12 documentation when appropriate and collaborates with Beacon Health Strategies for the admission of an Enrollee to an inpt Psychiatric unit when indicated.
    • Coordinates care between multiple behaviroal health and primary care team providers as needed. Identifies services and care delivery settings and recommends alternatives when appropriate.
    • Offers proactive review of members for a multidisciplinary care planning with PCPs and PCTs.
    • Supports the PCTs in the development, implementation and modification of Individualized Care Plans for NaviCare Enrollees, attending all PCT team meetings in PCP offices when applicable.
    • Updates all relevant PCT team members regarding the Enrollee’s mental health status and develops and/or proposes changes to the behavioral health care plan as appropriate.
    • Works collaboratively with the outreach team and Fallon ESR employees to assist in the smooth tranisiton of potential Enrollees who present with a defined behavioral health need including but not limited to: resources for medication compliance and appropriate in-network BH providers.

    Clinical documentation and data management and reporting 

    • Documents outcomes of initial and followup home visit outcomes in the CER within two business day of assessment, ensuring all PCT members are notified of any emergent needs and data entry completed immediately.
    • Completes referrals for all the Enrollee’s recommended behavioral health services, including outpatient supports, therapy, and medication management/assessment; ensures all PCT members and relevant caregivers are aware of referrals and goals.
    • Completes all referrals for as needed neuropsychiatric evaluation notifying all PCT team members of evaluation referral and documenting referralin CER.
    • Monitors daily psychiatric inpatient census log and contacts appropriate hospital staff to provide care coordination. Within one business day ensures notification of Enrollee’s psychiatric admission and forwards information to PCT team members for care coordination.
    • Reviews all of the medications at initial and follow-up assessments with Enrollees and forward results to the CM as indicated. Provide monthly case load reporting to Manager and Administrative Assistant.

    Monitors compliance 

    • Strictly observes HIPAA regulations and Fallon Heath policies regarding confidentiality of member information.
    • Strictly observes Fallon Health’s safety awareness policy when conducting homevisits.
    • Complies with all NaviCare reporting requirements.
    • Ensures timely filing with the appropriate Protective Services agency regarding any concerns about the safety and well being of an Enrollee.
    • Maintains an ongoing awareness of community clinical, psychiatric, and other outpatient resources as well as state and federal resources as needed. Adds resources to “Ready Reference” regularly.

    Provides training and consultation 

    • Serves as a behavioral health consultant to the NaviCare Primary Care Teams (PCT).
    • Works colaboratively with the NaviCare Geriatrician on clinical care issues.
    • Offers recommendations to NaviCare’s continued program development..
    • Works with Fallon Health Provider Relations and Beacon Health Strategies to ensure that contracted behavioral health providers are knowledgable about the NaviCare program requirements.
    • Discusses Enrollees who may benefit from Intensive Clinical Management, beyond the scope of Navicare’s BHCM care model, with Beacon Health staff Works collaboratively with Beacon’s staff to ensure quality and timely arrangement of necessary mental health supports.A
    • Attends weekly NaviCare and Beacon meetings.
    • Attends monthly supervision meeting with Manager and/or Director. Attends daily clinical team huddles and discharge meetings Participates in BHCM Team meetings at least four of which will occur at the central office. Physical presence is required.




    Master’s Degree in social work, psychology or nursing required



    LICSW or LMHC or nurse required.

    Certification relevant to areas of clinical practice in behavioral health highly preferred (i.e. Certificate of Geriatric Study, Certified Case Manager)



    • Previous behavioral health and/or care management experience for geriatric populations. At least 3-5 years geriatric outpatient or inpatient experience.
    • Experience developing behavioral health protocols a plus.     



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