Behavioral Health Care Coordinator (NARA IMCE)

Position Title: Behavioral Health Care Coordinator

Department: Population Health Partnerships

Title of Manager: High Risk Populations Program Manager

Supervises: Non-supervisory position

Employment Status: Regular – Exempt

Requisition: 17847

This position serves a culturally specific population who are members of NARA IMCE contract. Additionally, this position supports the development and implementation of groundbreaking Indian Managed Care Entity work in partnership with the Native American Rehabilitation Association (NARA) NW.

General Statement of Duties

The Behavioral Health Care Coordinator (BH CC) is responsible for providing assessment, care planning and service coordination and Intensive Case Management for members with complex or special health care needs and who are identified as high-risk due to behavioral health issues. The BH CC provides clinical expertise in mental health and alcohol and other drug related addiction (AOD) treatment in coordinating services for the purpose of improving member self-management and overall health outcomes. The BH CC acts as the primary Care Coordination liaison with state and community behavioral health providers and agencies. These functions include components of community-focused and population-based behavioral health care coordination, as well as System of Care principles that guide service delivery to children with mental health challenges and their families. Key partners in this process are the member and relevant family/caregivers, the primary care provider and any appropriate community partners and internal operational staff. The care coordination services are evidence-based and culturally-specific.

Specific Position Duties

Behavioral Health Care Coordinator (BH CC/AI AN): BH CC’s working with the American Indian/Alaska Native program work exclusively with American Indian (AI) and Alaskan Native (AN) OHP members according to established tribal and department protocols.

Behavioral Health Care Coordinator (BH CC/ENCC): BH CC’s working with the Exceptional Needs Care Coordination program may have their assignment changed based on member population changes and departmental needs.

Essential Position Functions

Clinical Assessment

• Assess overall risk of member, including physical condition, behavioral issues, mental status, social support system availability, and relationship with providers.
• Utilize assessment information to develop individualized plans of care for assigned members.
• Coordinate with providers to ensure consideration is given to unique needs in integrated planning and that care plans are timely and effective.
• Practice using a trauma-informed and client-centered approach with members by respecting their autonomy, exploring any ambivalence, meeting resistance with acceptance and following their lead in developing care plans.
• Identify suspected abuse and neglect issues and appropriately report to mandated authorities.
• Acknowledge member’s right to choice of treatment or refusal of treatment.
• Provide culturally and linguistically appropriate ICM services to members identified as Aged, Blind, and Disabled, members with special health needs (complex, high utilization, multiple comorbidities, and/or serious behavioral health issues) and those in Long Term Care services under the State’s 1915(i) State Plan Amendment.
• May provide individualized plans of care for high risk COA Plus members and review those plans with ICT team.

Care Coordination

• Accept assignment of and maintain a caseload of members based on behavioral health assessment or clinic assignment or placement in facility-based care; ensure members have access to appropriate care provider(s) who can meet their needs.
• Implement care coordination plan in collaboration with member, providers, case workers and other relevant parties.
• Effectively coordinate an interdisciplinary team for integrated care plan support of complex members.
• Confer with or co-manage complex medical and behavioral members with a peer RN Care Coordinator.
• May participate in monthly state hospital IDT meetings as well as discharge planning meetings.
• Participate in CCO/APD IDT meetings to coordinate care services for OHP members in long term care services.
• Coordinate and/or aid with coordinating community support and social services systems linkage with care systems, as deemed necessary and appropriate.
• Collaborate with primary care and community health care providers and staff, Aging and People with Disabilities caseworkers, Oregon Health Authority Innovator Agents and Client Services Unit staff, business partners, vendors, community agencies, and other relevant parties. (BH CC/AI AN will also collaborate with Tribal health leaders.)
• Provide direction as appropriate to non-clinical Care Coordination staff involved with the member.
• Creatively utilize available community resources as an adjunct to health plan benefits and follow-up to determine if these are received by the member.
• Involve PHP or Operations Medical Director (MD) for member resource needs that exceed Oregon Health Plan – Medicaid (OHP) and/or Centers for Medicare and Medicaid Services – Medicare (CMS) benefit packages or for situations that appear to warrant medical director review.
• Assist members to ensure timely access to providers and services.
• Assist providers with coordination of services on behalf of members.

Transition Assistance

• Respond to referrals from Medical Management Behavioral Health staff for transition services for COA members being discharged from psychiatric inpatient stay.
• Collaborate with discharge planners regarding OHP members with behavioral health needs who are discharging from hospital, residential, SNF care, or other facility care to the community.
• May ensure members on the state hospital Ready to Transition (RTT) list are prioritized for referral into appropriate transition setting.
• May compile and distribute referral packets to residential and foster care facilities as needed.
• Coordinate care for members residing outside of service area as required in contract.

Compliance

• Maintain unit compliance with Coordinated Care Organization and OHA requirements.
• Maintain tracking data for program evaluation and reporting purposes.
• Maintain timely and accurate documentation about each member per program policies and procedures.

• Maintain working knowledge of COA and OHP benefits, including Addictions and Mental health benefits.
• Report member complaints to Appeals and Grievance team for investigation and follow-up, per protocol.
• Assist Quality Assurance (QA) staff in identifying behavioral health providers with practice patterns which are not in conformity to best practice standards.
• Maintain unit compliance with the Model of Care requirements if applicable.

Essential Department and Organizational Functions

• Forward relevant information of members requiring special consideration of benefits to appropriate Medical Director for review. (BH CC/AI AN will forward this information to the Oregon Health Authority (OHA) Client Services Unit.)

• Serve as a resource to the organization on mental health and alcohol and other drug topics and issues.
• May provide coaching and training on specific job responsibilities to new employees in this role.
• Collaborate with CareOregon’s essential community partners in achieving improved health status for member populations and make referrals as appropriate.
• Follow ENCC, departmental, and organizational policies and procedures.
• Report to work as scheduled and follow attendance policies.
• Perform other duties and projects as assigned.
• Participate in quality and organizational process improvement activities and teams when requested.
• Participate in work-related continuing education when offered or directed.

Knowledge, Skills, and Abilities Required

• Knowledge of current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for mental health and substance dependence/abuse diagnoses, ASAM (American Society of Addiction Medicine) criteria for alcohol and/or drug dependence treatment and Mental health and addictions treatment modalities and best practice, basic concepts of managed care and ICD, CPT, and HCPCS codes and drug formularies
• Knowledge of co-morbidities that indicate potential for psychiatric de-compensation and/or relapse
• Knowledge of side effects of psychotropic medications that may impact health status and adherence with treatment recommendations and behavioral health integration in primary care settings

• Knowledge of the Oregon Health Plan benefit package, eligibility categories, and Oregon Medical Assistance Program (MAP) rules and regulations (BH CC/AI AN will maintain working knowledge of Native American Oregon Health Plan Fee For Service program benefits)

• Knowledge of Medicare parts A and B benefit packages and the Centers for Medicare and Medicaid Services (CMS) rules and regulations and community resources
• Knowledge of culturally-specific issues, resources and strengths of the populations served (BH CC/AI AN will have knowledge of culturally-specific issues, resources and strengths of the AI AN populations)
• Knowledge of community resources
• Ability to conduct psychosocial assessments, including history of mental and physical disabilities, alcohol and drug use, past mental health and criminal justice contacts, family and social relationships, and level of functioning, mental status examination and formulate multiaxial DSM impressions and mental health risk assessments and intervene accordingly, if indicated

• Ability to assess the quality of AOD assessments, treatment and discharge plans, as well as patient outcomes, synthesize complex medical and behavioral health diagnostic information to assist providers and other care coordinators in treatment planning and write and supervise an individual plan of care
• Ability to exercise sound clinical judgment, independent analysis, critical thinking skills, and knowledge of behavioral health conditions to determine best outcomes for members and access mental health and addictions treatment for members
• Ability to meet department standards for competency in the use of motivational interviewing within 12 months of hire, collaborate with members, providers, and community partners to develop plans to address complex care needs and monitor and evaluate a plan of care for optimal outcomes
• Ability to work in an environment with diverse individuals and groups
• Ability to establish collaborative relationships and effectively lead a multidisciplinary team
• Ability to manage multiple tasks and to remain flexible in a dynamic work environment and work autonomously and effectively set priorities
• Ability to provide excellent customer service and verbal and written communication
• Basic word processing skills

Physical Skills and Abilities Required

Lifting/Carrying up to 10 Pounds

Pushing/Pulling up to 0 Pounds

Pinching/Retrieving Small Objects

Crouching/Crawling

Reaching

Climbing Stairs

Repetitive Finger/Wrist/Elbow/

Shoulder/Neck Movement

0 hours/day

0 hours/day

0 hours/day

0 hours/day

0 hours/day

0 hours/day

More than 6 hours/day

Standing

Walking

Sitting

Bending

Seeing

Reading

Hearing

Speaking Clearly

0 hours/day

0 hours/day

0 hours/day

0 hours/day

More than 6 hours/day

More than 6 hours/day

More than 6 hours/day

More than 6 hours/day

Cognitive and Other Skills and Abilities

Ability to focus on and comprehend information, learn new skills and abilities, assess a situation and seek or determine appropriate resolution, accept managerial direction and feedback, and tolerate and manage stress.

Education and/or Experience

Position requires Master’s degree in social work, counseling or other behavioral health field. This position also requires a minimum of three (3) years of increasingly responsible experience in mental health and/or drug and alcohol treatment for the population being served. Preference will be given for current Licensed Clinical Social Worker (LCSW) or Licensed Professional Counselor (LPC) license, experience with a similar population in health plan case management/care coordination or behavioral health integration in a person-centered primary care home, experience administering the Oregon Health Plan (OHP) (Medicaid) and the Centers for Medicare and Medicaid Services (CMS) (Medicare) benefits, related experience in the use of Motivational Interviewing (MI), certification as CCM (Certified Case Manager) and certification as Certified Alcohol Drug Counselor II or III (CADC II or III).

Working Conditions

• Environment: This position’s primary responsibilities typically take place in the following environment(s) (check all that apply on a regular basis):

• Inside/office Clinics/health facilities Member homes

• Other_________________________________________

• Travel: This position may include occasional required or optional travel outside of the workplace, in which the employee’s personal vehicle, local transit, or other means of transportation may be used.
• Equipment: General office equipment
• Hazards: n/a

Candidates of color are strongly encouraged to apply. CareOregon is committed to building a linguistically and culturally diverse and inclusive work environment

Veterans are strongly encouraged to apply.

Equal opportunity employer. This company considers all candidates regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.