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 Behavioral Health Case Manager (BHCM) is responsible for assessing a member’s behavioral and social care needs and developing and implementing a care plan to address all identified issues. The BHCM serves as an active participant on the member’s Care Team  and an advocate for the member. The BHCM is actively involved with the member from time of psychiatric admission through discharge and ensures all Care Team members and healthcare providers are aware of member’s status. The BHCM facilitates prompt access to outpatient mental health supports, and community resources. The BHCM collaborates and works with members of the care team at both Fallon Health and community resources (Partners) during period of member transition of care.

May attend in person care planning meetings, care coordination meetings, partner communication meetings, and other face-to-face meetings with providers, partners, and members to perform assessments, train staff, coordination communication and otherwise represent Fallon Health in a positive way.

Primary Job Responsibilities:

Assessment and care plan coordination

• Contacts Members and Caregivers/guardians telephonically and/or in person  after receiving a BH referral to:
•        Conduct behavioral health assessment(s) and administer other assessment tools as indicated;
•        Assess and address the mental health and social care needs of the members;
•        Recommend modifications to the member’s integrated care plan if present
• May completesa home visit for all agreeable referred members within alloted time frames and in the event of an emergent mental health or social care need or as 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
• May complete home visits and follow up assessments after all BH hospitalizations/Transitions of Care
• May completes home visits to assist members with applications for indicated government and community programs including SNAP, housing, prescription assistance, etc.
• Maintains an ongoing awareness of clinical, social, and financial resources available in the community as well as State/Federal and national resources
• Coordinates and works with governmental, private, civic, religious, business and/or other groups to arranges and coordinate plans for members served in the Program
• Assists members in establishing or reinforcing a social support network, thereby reducing their dependence on the medical system.
• Offers proactive review of members for a multidisciplinary care planning with PCPs and Care Teams
• Supports the Care Teams in the development, implementation and modification of Individualized Care Plans for Members, attends Care Team team meetings including those in provider offfices, community partner locations, office locations and otherwise
• Updates all relevant Care Team members regarding the member’s mental health and substance use status and develops and/or proposes changes to the behavioral health care plan as appropriate
• Works collaboratively with the outreach team and Fallon NaviCare ESR or other employees to assist in the smooth transition of potential members who present with a defined behavioral health need including but not limited to:  resources for medication compliance and appropriate in-network BH providers
• Participates in monthly supervision with leader
• Performs other responsibilities as assigned by Clinical Intergration Leadership Team

Clinical documentation and data management and reporting

• Documents outcomes of initial and follow up home visits in the documentation system per department guidelines ensuring all Care Team members are notified of any emergent needs and data entry completed immediately
• Completes referrals for all the member’s recommended behavioral health services, including outpatient supports, therapy, and medication management/assessment; ensures all Care Team members and relevant caregivers are aware of referrals and goals. Documents all activity in the documentation system per department guidelines
• Completes/facilitates referrals for needed neuropsychiatric evaluation(s) notifying all Care Team team members of evaluation referral and documenting referral activity in the documentation system
• Monitors daily inpatient BH census log and contacts appropriate hospital staff  to provide care coordination (as long as member has not restricted the facility to share information with Fallon). Within one business day ensures notification of member’s psychiatric admission and forwards information to Care Team members for care coordination.  Documents all activity in the documentation systemper department guidelines.
• Reviews all of the medications at  initial and follow-up assessments with members and forward results to the Nurse Case Manager or PCP as indicated.  Documents all activity per department guidelines
• Initiates and updates Care Plan in the documentation system on all active members in the BHCM panel per Care Plan Process for products per workflows and requirements
• Completes daily tasks/ outreach to members and identifies appropriate assessments to be completed within timelines

Monitors compliance

• Strictly observes HIPAA regulations and Fallon Health’s policies regarding confidentiality of member information
• Strictly observes safety awareness and home visit process when conducting home visits
• Complies with all reporting requirements and processes as applicable
• 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 

 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
• Attends and participates in team’s monthly medical rounds case presentations

Education:

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

License/Certifications:

• Active, unrestricted license as a LICSW and/or LMHC ; reliable transportation
• Certification in Case Management a plus
• Satisfactory Criminal Offender Record Information (CORI) results

Experience:

• A minimum of three years’ clinical experience in the behavioral health/mental health setting required. 
• Experience with government programs, community resources, case management, substance use disorders and/or severe and persistent mental illness preferred.

Demonstrates proficiency 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

Resources (systems, etc.) used inperforming role

Microsoft products (Word, Excel, Visio, PowerPoint, Outlook); MS Teams; reporting software such as Business Objects; CaseNET TruCare System; QNXT System, Provider EMRs as applicable

Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.