PACT Liaison Care Prtner Details

PACT Liaison Care Prtner

Commonwealth Care Alliance - Boston, MA

Employment Type : Full-Time

• Facilitates and coordinates with PACT team's preventative and basic primary care to members, as needed, per CCA standard operating procedures, commonly accepted medical guidelines, and appropriate scope of practice.
• Establish regular contact with PACT teams for member reviews to support the management of chronic disease or end of life.
• Respond to member direct requests and subsequently communicate with relevant PACT teams on these requests to ensure comprehensive care coordination for member.
• Assist the member and PACT teams with understanding members CCA Health Benefit package. Providing training and education to PACT teams regarding CCA benefits and related programs.
• Tracks MDS due dates and assist in scheduling MDS assessments.
• Adheres to appropriate and complete documentation practices, including: history of present illness, adjustment or maintenance of an established treatment plan, and consistent follow up of the plan as evidenced in the documentation.
• Performs episodic urgent medical/ behavioral health notification to the PACT team to ensure that timely and appropriate medical care, in order to avoid emergency department, visit or hospitalization.
• Notify PACT teams on all medical and psychiatric admissions and collaborate with the BH Utilization Management Team and Medical Transitions of Care Team to assist in discharge planning, as appropriate.
• Performs detailed medication reconciliation, as appropriate, based on licensure
• Take ownership of the provider relationship, ensuring all provider needs and concerns are addressed and answered.
• Ensures appropriate LTSS are in place and collaborates with PACT teams and GSSC/LTSC on members' needs
• Review the Quality Gap Report weekly and addresses clinical quality gaps (e.g., HEDIS), collaborating with the PACT teams, along with the member's PCP
• Liaises with CCA interdisciplinary site team to ensure comprehensive member needs are consistently met.
• Manages panel-wide and member-specific utilization trends.
• Liaises with CCA and community-based PCPs/specialists on behalf of member and PACT teams.
• Ensures appropriate documentation of visits and activities within CCA's central enrollee record and within 48 hours of visits
• Participates in Interprofessional Team Meetings
• Adjusts the member-centered plan of care as necessary based on a significant change in condition. A change in condition is an event (hospitalization, acute illness, etc.) which results in either a short- or long-term change in need (examples include adding in Palliative care, increasing personal care hours short term post hospitalization, or purchasing high cost durable medical equipment for a non-reversible functional change)
• Utilizes Clinical Decision Support Tools, team meetings, and consultation with CCA specialists, authorizes proposed equipment and/or services for the implementation of the individualized plan of care and collaborates with CCA Utilization Management staff to ensure appropriate medical necessity criteria are met. Participates in utilization and case review as necessary.
• Provide clinical care to members via telehealth technologies (video, chat, etc.) for a clinically appropriate clinical care and care management services.
• Will take over care management responsibilities for Health Home members who have been admitted to DMH Intermediate Care facility for over 90 days with no plan for discharge.

• Master's Degree in Social Work, Mental Health Counseling or Psychology
• Licensure with the Commonwealth of Massachusetts as a LICSW, LMHC, Psy-D, or PhD in good standing
• OR Bachelor's Degree in nursing with relevant required experience in behavioral health and licensure in good standing.
• OR Associates Degree or Diploma in Nursing

• 3+ years meaningful clinical experience in community case management, telephonic case management or primary care.
• Experience with Massachusetts Depart of Mental Health programs
• Experience caring for patients/members with complex medical, behavioral health, and social needs strongly preferred

• Deep knowledge of and experience with Department of Mental Health and their services such as PACT/ACCS/Intermediate Care
• Demonstrated commitment to and interest in improving health outcomes among marginalized and underserved populations
• Proven ability to work independently as a self-starter, to identify key tasks needed to accomplish project objectives, facilitate issue identification, problem-solving and decision-making
• Excellent organizational, time-management and problem-solving skills
• Ability to function effectively as part of a multi-disciplinary team
• Curiosity and creativity
• Effective oral and written skills
• Strong interpersonal skills
• Strong attention to detail
• Willing to learn and utilize telehealth technologies (video, chat, etc.), when appropriate, for a variety of clinical care and care management services.