Behavioral Health and Recovery Plan Integrated Care Manager

Empower. Unite. Care. Position Overview MetroPlusHealth is committed to empowering New Yorkers by uniting communities through care. We believe that health care is a right, not a privilege. If you have compassion and a collaborative spirit, work with us. You can come to work being proud of what you do every day. The BH HARP Integrated Care Manager develops, facilitates, and communicates a plan of care in partnership with the member, their assigned Health Home, primary caregiver, medical specialists, the primary and attending physicians, and various mental health and/or substance use disorder providers. This position collaborates with the aforementioned parties to assess, plan, facilitate, and advocate for options and services to meet a member’s medical and behavioral health needs through communication and available resources. Responsibilities Manage a caseload of HARP members with medical risk factors and those with high‑risk medical diagnoses discharging out of inpatient admissions. Clinically assess members for acute physical health and behavioral health needs following inpatient admissions for medical reasons. Generate referrals to providers, community‑based resources, and appropriate services and other resources to assist in goal achievement. Develop a formal plan of care for all services needed for the member. Notify physicians for any changes in member’s plan of care and follow up with assigned nurses for clinical updates to plans of care. Document Interdisciplinary Team care coordination notes between internal MetroPlusHealth staff and external health providers and caregivers. Attend and prepare for Interdisciplinary Care Team meetings featuring newly enrolled, frequently admitted, high‑utilizing at‑risk members. Assist members with the coordination of services from various settings as appropriate, including facilitating discharge from acute settings and alternate settings. Provide care coordination throughout the continuum of care and optimize both quality of care and quality of life for MetroPlusHealth members. Educate members on health‑related conditions and support them in addressing gaps in health care through connections to direct care providers, resources, and medications as appropriate to their conditions. Document in a comprehensive manner to ensure that all goals, interventions, and care coordination activities for each member in the EMR system and other applicable software programs comply with professional standards and regulatory guidelines. Evaluate SDOH needs and assist in connecting members to resources in their community. Contribute to MetroPlusHealth corporate goals through ongoing execution of member care plans and achievement of member goals. Be accountable to the HARP Medical Director, conference cases with the Medical Director as outlined by supervisory staff, and track health outcomes as required. Perform other appropriate duties and participate in special projects such as audit review, quality improvement, community health education, facility/provider relations, and marketing activities. Required Education, Training & Professional Experience Master’s Degree in health care or related field (required). 3–5 years of medical and behavioral health experience, preferably in an inpatient hospital, with focus on serious mental illness and substance use disorder. 1–3 years of managed‑care case‑management experience. Working knowledge of NY State Health Home System and plan‑of‑care process. Case‑management experience within the integrated collaborative care model approach. Previous history of conducting discharge planning and providing direct education around medical conditions. Knowledge of Psyckes, E‑Paces, HCS (UAS) MAPP, Microsoft Teams video knowledge preferred. Medical background and bilingual preferred. Licensure and/or Certification Required A valid license and current registration to practice as a psychologist, licensed mental‑health counselor (LMHC), licensed marriage and family therapist (LMFT), licensed master social worker (LMSW), or licensed clinical social worker (LCSW) issued by the New York State Education Department is required. Professional Competencies Integrity and trust. Customer‑service mindset focused on members. Superior technical computer skills (Microsoft Office, DCMS, Teams Video application). Exceptional organizational and communication skills. Strong interpersonal and assessment skills; the ability to remain calm and poised with challenging members who often present in a constant state of crisis. #J-18808-Ljbffr MetroPlusHealth