Pop Health & C3 Behavioral Healthcare Coordin

Position Summary

The Behavioral Health Care Coordinator plays a pivotal role as a core member of the collaborative care team, working alongside the enrollee’s medical provider, mental health team, and the larger Concierge Care Coordination team.

This position is responsible for coordinating and supporting the mental and physical health care of enrollees within an assigned behavioral health population caseload.

The coordinator collaborates with medical providers and, when appropriate, other mental health providers, to manage care for all lines of business, including managed care contract programs that serve adults and children with severe mental illness (SMI).

Key responsibilities include coordinating healthcare interventions across the continuum of care, from complex medical conditions to chronic disease management, while promoting compliance with preventative care measures.

The Behavioral Health Care Coordinator facilitates coordination of care at the safest and most appropriate level, focusing on closing immediate care gaps and empowering members to self-manage chronic conditions.

By complementing the practitioner-patient relationship and supporting the established plan of care, the coordinator utilizes cost-effective, evidence-based practice guidelines to enhance the member’s quality of life.

The primary goals are to address acute needs, prevent or delay the progression of severe disease stages, and reduce complications and morbidities, ultimately improving health outcomes and lowering healthcare costs.

Job functions are performed in accordance with the requirements of the Medicaid contract, Florida Healthy Kids (FHK) contract, Community Care Plan (CCP) policies and procedures, and Patient-Centered Medical Home (PCMH) standards.

Qualifications

• Bachelor's degree in Nursing (BSN) or a Licensed Clinical Social Woker (LCSW) with Master's degree in Social Work (MSW)

Certificates and Licenses

• Current, unrestricted Registered Nurse (RN) license in the State of Florida (required for candidates with a Nursing degree).
• Current, unrestricted Licensed Clinical Social Worker (LCSW) license (required for candidates with a Social Work degree).
• Certified Case Manager (CCM) preferred.
• Psychiatric-Mental Health Nursing Certification (PMH-BC), Certified Addictions Registered Nurse (CARN), or other applicable behavioral health certification preferred, as appropriate to discipline.

Experience

• Minimum three (3) years of clinical experience in behavioral health, mental health, substance use, care management, or a related behavioral/mental healthcare setting required.
• Experience in care management, case management, care coordination, population health, or a managed care/health plan setting preferred.
• Experience coordinating behavioral health, medical, and social needs across multidisciplinary providers and healthcare settings preferred.
• Knowledge of Medicaid, managed care, behavioral health services, and applicable healthcare regulatory and accreditation requirements preferred.

Essential Duties and Responsibilities

Behavioral Health Assessment & Individualized Care Planning

• Conduct comprehensive assessments to identify behavioral health, medical, substance use, psychosocial, functional, social, and other needs, barriers to care, risk factors, and support needs.
• Develop and maintain individualized, member-centered care plans in collaboration with members, families/caregivers, providers, and the multidisciplinary care team, as appropriate.
• Establish measurable goals and interventions based on identified needs, member priorities, and the established plan of care.
• Review and update assessments and care plans based on changes in condition, care needs, services, and applicable program requirements.
• Identify gaps in care, barriers to treatment, and other needs requiring intervention and coordinate appropriate follow-up.

Behavioral Health Care Management & Ongoing Monitoring

• Provide ongoing care management and clinical follow-up based on individual member needs, risk, level of acuity, and applicable program requirements.
• Monitor changes in behavioral and medical health status, treatment plans, medications, utilization, services, and other factors that may impact the member's health or care needs.
• Review relevant clinical information and healthcare utilization to identify changes in condition, emerging needs, gaps in care, or opportunities for intervention.
• Coordinate timely follow-up, in accordance with departmental procedures, following behavioral health or medical hospitalizations, emergency department visits, crisis events, and other significant changes in health status or care needs.
• Identify and address barriers to treatment, medication adherence, appointments, preventive care, behavioral health services, substance use treatment, and other identified healthcare needs.
• Conduct outreach to members with patterns of emergency department visits, hospitalizations, or other utilization concerns to identify contributing factors and support appropriate interventions.
• Identify significant behavioral health or clinical concerns and escalate issues requiring additional review to appropriate clinical leadership or the Medical Director.

Care Coordination, Member Support & Collaboration

• Serve as a primary care coordination resource for members and families/caregivers, as appropriate, facilitating communication and continuity of care across behavioral health, medical, and community-based providers and services.
• Coordinate with behavioral health providers, primary care providers, specialists, hospitals, substance use treatment providers, community resources, and other members of the care team based on individual member needs.
• Support safe and effective transitions of care following hospitalization, crisis stabilization, changes in level of care, or transitions between healthcare settings and services.
• Educate and support members regarding their care plan, available services and resources, treatment adherence, self-management strategies, and other identified healthcare needs.
• Utilize appropriate engagement and evidence-based behavioral health techniques within professional scope and departmental guidelines to support member participation and progress toward established goals.
• Participate in or facilitate multidisciplinary care conferences when indicated by member needs and collaborate with internal and external stakeholders to support coordination of care.
• Identify psychosocial and social barriers that may affect care and coordinate referrals to appropriate internal or community resources.
• Conduct or participate in home or community-based assessments when required or indicated by applicable program or contractual requirements.

Documentation & Program Requirements

• Maintain complete, accurate, and timely documentation of assessments, care plans, interventions, member interactions, provider coordination, and other care management activities in accordance with departmental and program requirements.
• Ensure care management documentation and required activities are completed in accordance with applicable contractual, regulatory, and accreditation requirements.
• Complete required program documentation and reporting activities within established timeframes.
• Identify and address documentation gaps or discrepancies and maintain supporting information necessary for applicable program, audit, or accreditation review.

Quality, Compliance & Program Support

• Perform care management activities in accordance with applicable contractual requirements, departmental policies and procedures, accreditation standards, and established clinical guidelines.
• Maintain member confidentiality and protect health information in accordance with HIPAA and organizational requirements.
• Participate in departmental case reviews, multidisciplinary discussions, training, quality improvement activities, and other initiatives supporting behavioral health programs.
• Identify recurring member, provider, service, or operational barriers and communicate concerns and opportunities for improvement to departmental leadership.

This job description in no way states or implies that these are the only duties performed by the employee occupying this position. Employees will be required to perform any other job-related duties assigned by their supervisor or management.

Skills and Abilities

• Effective clinical assessment and critical-thinking skills with the ability to identify behavioral health, medical, psychosocial, and care coordination needs and appropriate interventions.
• Ability to assess and coordinate behavioral health, substance use, medical, psychosocial, functional, and social needs of members across varying levels of acuity and complexity.
• Effective care management and care planning skills, including the ability to develop, implement, monitor, and update individualized, member-centered care plans.
• Ability to coordinate care and communicate effectively across behavioral health and medical providers, hospitals, substance use treatment providers, community resources, and multidisciplinary care teams.
• Effective member engagement, education, and communication skills, with the ability to communicate healthcare information in a clear, supportive, and understandable manner.
• Sound clinical judgment, problem-solving, and decision-making skills, including the ability to recognize behavioral health risks, changes in condition, crisis needs, or other concerns requiring timely escalation or additional clinical review.
• Excellent written, verbal, interpersonal, and clinical documentation skills.
• Effective organizational and time-management skills with the ability to manage an assigned caseload, prioritize member needs based on acuity and risk, and balance competing priorities.
• Attention to detail with the ability to maintain accurate and timely care management