Pop Health Behavioral Healthcare Coordinator

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.

Essential Duties and Responsibilities

• Team Leadership and Coordination: Lead a multidisciplinary team to identify high-risk clients, address care gaps, and collaborate with providers to enhance patient outcomes and care quality.
• Comprehensive Care Coordination: Manage services for medical, behavioral, and substance use needs, including crisis intervention, discharge planning, and complex case management. Engage with Medical Directors and care management staff to direct appropriate utilization and data capture. Educate members, providers, and team members on care coordination services and the proper use of these services, including reducing inappropriate admissions and placements.
• Crisis and Service Coordination: Manage care coordination for enrollees requiring medical and behavioral health services, including crisis intervention, behavioral health triage, and the coordination of psychiatric and substance use disorder services. Conduct thorough needs assessments, including risk stratification, to determine health, psychological, educational, and social needs.
• Daily Census Review and Discharge Planning: Review the daily census for enrollees admitted to the hospital within your panel, assess the need for ongoing care coordination, and facilitate discharge planning. Assess hospitalized enrollees for ongoing needs in care coordination, disease management, and closing gaps in care by working closely with hospitals and providers.
• Outreach and Engagement: Conduct outreach to enrollees with patterns of emergency room visits to identify contributing factors and develop strategies to reduce avoidable admissions. Provide outreach to enrollees with chronic conditions or multiple care gaps to support preventive care and improve management.
• Needs Assessment and Individualized Care Planning: For all identified enrollees, conduct comprehensive needs assessments and develop individualized care plans in collaboration with physicians and enrollees. Establish specific, measurable, achievable, realistic, and time-bound (SMART) goals to address identified needs, enhance quality of life, and evaluate the cost and quality outcomes of the care provided.
• Team Collaboration and Communication: Participate in team huddles and multidisciplinary team conferences as needed to review strategies, address immediate needs, and develop action plans for quality care. Collaborate with healthcare teams to assess progress toward health care goals and optimize patient adherence to care plans, including medication adherence and preventive screenings.
• Barrier Assessment and Care Plan Updates: Identify and assess barriers when members do not meet treatment goals, fail to follow care plans, or miss appointments. Update member care plans as changes occur and communicate with the multidisciplinary team to ensure continuity and appropriateness of care.
• Member Education and Empowerment: Provide education on disease processes, healthy lifestyle changes, and self-management strategies consistent with clinical practice guidelines. Empower members through shared decision-making tools and support self-management efforts to enhance their quality of life.
• Behavioral Health Interventions and Support: Deliver brief behavioral interventions using evidence-based techniques such as motivational interviewing, problem-solving treatment, or behavioral activation. Support the practitioner-patient relationship with a focus on preventing disease exacerbation and complications.
• Community Integration and Home Assessments: In conjunction with the Concierge Care Coordination Health Social Worker, conduct in-home assessments as needed to evaluate the member’s home environment for safety, setting appropriateness, and the availability of needed supplies and medications.
• Resource Optimization and Quality Improvement: Monitor resource utilization, including hospitalizations and long-term care services, to promote optimal use consistent with organizational goals. Participate in the development of programs, policies, and procedures to drive continuous quality improvement in care coordination.
• Documentation and Compliance: Maintain accurate documentation in compliance with quality standards and accreditation requirements for care management programs. Uphold patient confidentiality in all aspects of care and adhere to HIPAA guidelines and organizational policies.
• Liaison and Reporting: Serve as a liaison between members, providers, medical directors, and external organizations to coordinate care and resolve authorization issues. Prepare and present reports on department activities as required.
• Additional Responsibilities: Refer cases to medical directors for questionable or inappropriate treatment regimens, and complete other projects, assignments, and duties as assigned.

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.

Qualifications

• Bachelor’s Degree in social work and/or Nursing.
• Master’s Degree in social work (MSW) or Nursing (Preferred)
• Psychiatric/Mental Health Nursing Certification (Preferred)

Certificates and Licenses

• Registered Nurse licensure in the state of Florida, or State Licensure in Social Work or related field (Preferred)
• Certified Case Manager (Preferred)
• License Clinical Social Work (LCSW), Licensed Mental Health Counselor (LMHC) – (A Plus)
• Psychiatric- Mental Health Nursing Certification (A Plus)
• Certified Addictions Registered Nurse (CARN) (A Plus)

Experience

1. Clinical Experience: 3-5 years of clinical experience

2. Experience in Managed Care/Health Plan Setting: 3-5 years of experience in a managed care, health plan, or insurance setting, particularly in behavioral health or disease/case management roles.

3. Experience with Utilization Management and Care Coordination: Experience coordinating care across medical, behavioral, and social service providers, including familiarity with utilization management processes, appeals, and authorizations.

4. Knowledge of Medicaid/Medicare Regulations: Experience working with Medicaid, Medicare, or other state and federal health care programs, including knowledge of relevant regulations and compliance requirements.

5. Knowledge of Microsoft Office and internet software

6. Knowledge of EPIC and/or JIVA (preferred)

Skills and Abilities

• Exceptional Interpersonal Communication Skills: Demonstrated ability to collaborate and communicate effectively in a team setting, with a focus on building and maintaining professional relationships with enrollees and other members of the care team.
• Oral and Written Communication: Excellent oral and written communication skills, with strong problem-solving abilities. Proficiency in speaking effectively before groups of customers, employees, or other stakeholders within the organization.
• Self-Motivation and Independence: Ability to self-motivate and work independently with minimal supervision, demonstrating strong organizational, problem-solving, and decision-making skills.
• Analytical and Critical Thinking: Strong analytical skills and problem-solving ability, with a focus on reviewing clinical information, assessing needs, and developing tailored care plans to improve member outcomes.
• Experience with Mental Health and Substance Use Disorders: Proficiency in screening for common mental health and/or substance use disorders, conducting assessments, and developing treatment plans. Working knowledge of differential diagnosis, evidence-based psychosocial treatments, and brief behavioral interventions, such as motivational interviewing, problem-solving treatment, and behavioral activation.
• Basic Knowledge of Psychopharmacology: Understanding of psychopharmacology for common mental health disorders within the appropriate scope of practice, including the ability to educate and support enrollees regarding medication management and treatment adherence.
• Engagement and Therapeutic Relationships: Ability to effectively engage enrollees in therapeutic relationships, both in pers