ACO Behavioral Health Care Coordinator - Great Barrington, United States - Community Health Program Inc

Community Health Program Inc Great Barrington, United States

1 week ago

Description

ABOUT THE ORGANIZATION

Community Health Programs is a network of health centers and caring professionals that provide outstanding primary and preventive care for patients of all ages. What's truly unique to CHP is our broad spectrum of support services that extend beyond medical and dental issues to strengthen families and improve children's well-being. The region is a federally designated rural community and a Medically Underserved Population Area.

Community Health Programs embraces its role as a nonprofit health care provider and community partner. We are a leader in the communities we serve by providing high quality healthcare, dental services, wellness education and family support services. CHP outreach provides free health screenings, insurance enrollment assistance as well as information so people can learn how to take better care of themselves and their families.

Salary: $65,000-$74,000 / Annually The ACO Behavioral Health Care Coordinator provides specialty case management to high-risk patients enrolled in the Health Collaborative of the Berkshires. This candidate works directly with patients, patients families, physicians, and other care managers to assess the needs and strengths of high-risk patients and develop customized, proactive care plans that support patients optimal functional status and well-being. Data-driven monitoring of the effectiveness of the BH care plan as well as regular collaboration with the PCP team and other relevant stakeholders will be required. The BH Care Coordinator works collaboratively with other members of the health care team to ensure timeliness and coordination of services in compliance with documented care plan goals and objectives. Scope of practice includes but is not limited to assessment, brief intervention, and care management for patients with identified BH/SUD conditions and/or otherwise psychosocially complex issues. Encounters with patients may occur via phone, face-to-face at the providers office, within the hospital setting or within the community, according to the needs of the patient. The BH Care Coordinator identifies high risk populations and provides BH care coordination and support. This candidate works closely at the interface of many departmental and hospital-based services as well as primary care and other specialty practices. This person will support CHPs mission, vision, and values and will adhere to compliance protocols as well as CHPs policies and procedures.

POSITION REQUIREMENTS

ACO Behavioral Health Care Coordinator Essential Duties and Responsibilities:

Work directly with high-risk members with complex BH/SUD conditions.
Develop and implement individual, coordinated care plans in collaboration with the member and PCP or specialist, as well as community resources.
Create care plans to include clearly defined, actionable, measurable, and time-sensitive goals and objectives; progress against the plan is documented in the medical chart.
Act as an advocate in assisting the patient in navigating health care and community support systems.
Support the physician plan of care and intervene with knowledge of BH/SUD conditions to minimize risk and ensure compliance with evidence-based best practices. Including but not limited to initiating and facilitation case conferences.
Complete a comprehensive assessment for social, cultural, and social determinants of health impact for patients and ensures that realistic and effective referrals for community and financial resources are implemented as well as monitored for timeliness and impact.
Identify, align, and utilize health plan, health system and community resources that impact high risk care.
Work with community-based groups to address service gaps and serve as liaison to social and health resources.
Skilled in motivational interviewing, behavioral activation, CBT, health promotion and self-management, health education, crisis intervention, brief treatments for mental health and substance use problems, and medication assisted treatments.
Support CHP baseline staff in day-to-day patient care coordination.
Complete daily transitional care management (TCM) follow up calls.

Competencies: To perform the job successfully, an individual should demonstrate the following competencies:

Proven excellent leadership, and strong interpersonal, communication and team-building skills.
Proven collaboration & negotiation skills with providers, patients, families, insurance organizations and government agencies.
Proven ability to work independently and adjust to multiple demands and shifting priorities, ambiguity, and rapid change with resiliency.
Computer literacy required with ability to manage multiple open applications.
Ability to maintain and monitor confidentiality of patient records.
Ability to work autonomously and with meeting goals for productivity.
Ability to work collaboratively with all staff members of the ACO, including teams at CHP, BHS and Fallon.

Essential Skills and Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Ability to form positive and professional engagement and collaborative working alliances with patients and families.
Ability to form rapid engagement and alliance building with patients and their families.
Ability to follow the logical management of a members care throughout the continuum of care.
Possesses a basic understanding of applying clinical criteria when determining medical necessity.
Experience with care coordination.
Flexibility to adapt to varying work environments and site locations.

Experience:

2 years experience with a chronically ill population required. Background with all age populations preferred.
Demonstrated experience in the effective assessment and engagement of individuals with BH/SUD conditions.
Experience working in a healthcare setting as a member of a professional clinical team required.
Knowledge of community resources and support, BH/SUD treatment as well as experience in referral for treatment, support and services is required.
Experience in providing evidence-based brief interventions to individuals with BH/SUD conditions including Motivational Interviewing, Behavioral Activation, CBT, and Problem-Solving Tx.

Education and Training:

Master's Degree in social work or related clinical healthcare field required.

License/Certification:

LCSW, LICSW, LMHC preferred.
Recovery Coach Certification preferred.

FULL-TIME/PART-TIME Full-Time

POSITION ACO Behavioral Health Care Coordinator

EXEMPT/NON-EXEMPT Exempt

LOCATION MA, Great Barrington, CHP Administrative Offices

EOE STATEMENT

We are an equal employment opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status or any other characteristic protected by law.

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