Title: Behavioral Health Care Manager, Maternal Newborn
Reports to: Manager of Care Management
Classification: Individual Contributor
Location: Boston
Job description revision number and date: V 3.0; 8.18.2023
Organization Summary:
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.
Job Summary:
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 people living with complex and/ or chronic 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.
BH Care Manager supports high-risk pregnant and post-partum members who are at risk for an adverse delivery based on complex social, behavioral, and health needs with consideration of all levels of healthcare disparity. This CM provides ongoing management of the mother and newborn for 12 months post-partum, connecting members with appropriate social services and promoting self-management of their behavioral and medical needs. The BH Care Manager is a key member of an interdisciplinary team in the development and implementation of a care plan to enhance the members overall prenatal/postpartum health, and to achieve appropriate utilization. They will also assess plans, implement, coordinate, monitor, and evaluate care plans, services, and outcomes to maximize the maternal/child health of members.
*This role is currently hybrid in accordance with Mass DOH Covid prevention guidelines. Upon lifted Covid restriction, it may require a health center, medical/BH hospital facility, community, or home-based work.
Responsibilities:
Conducts Comprehensive Assessments
Facilitates medication reconciliation with pharmacist, RN and/or primary care team
Engages members and caregivers in active care planning with a focus on, medical, behavioral, social, and 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
Meet members where theyre at in other community settings including home or shelter
Assesses the members knowledge of their medical, behavioral health and/or social conditions and provides education and self-management support based on the members 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 creates and maintains a comprehensive inventory of local community resources through a web-based application, improving accessibility for members and 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 EHRs
Provides coverage for team members who are out of office
Other duties as assigned
Required Skills:
Demonstrated success in working as part of a multi-disciplinary team including communicating and working with Providers, Pharmacists, Nurses, Community Health Workers, and other health care teams
Ability to flexibly utilize clinical expertise to solve complex problems
Experience working with patients with chronic and behavioral health needs
Must be flexible and adaptable to change
Demonstrate the ability to work independently
Must demonstrate excellent interpersonal communication skills
Additional qualities that would be a good fit for our team include enthusiasm and passion for helping patients, genuine spirit, kind, and empathetic nature, and one who embraces a go with the flow mentality
Experience using appropriate technology, such as computers, for work-based communication
Experience and proficiency with Microsoft Office and online record keeping Must be able to remain in a stationary position 50-75% of the time
Desired Other Skills:
Experience working with Maternal/Newborn and/or Post-Partum population preferred
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)
Masters degree in Psychology, Social Work, or related field
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
** In compliance with Covid-19 Infection Control practices per Mass.gov recommendations, we require all employees to be vaccinated consistent with applicable law. **
