CCBHC Targeted Case Manager

Job Summary:   The goal of the Certified Community Behavioral Health Center (CCBHC) is to improve patient health outcomes and supporting clients in the behavioral, mental health and social determinant needs by supporting the navigation to and coordination of clinical and non-clinical services. The CCBHC will deploy a high-quality, consistent set of protocols including screening, intake, outreach, navigation and coordination services that help connect clients in need to critical services.

Duties:

• Services will be driven by completion and review of PRAPARE and other assessment tools, as well as the individualized goals of the client, with the primary role of improving the client’s quality of life by reducing the Social Determinates of Health that negatively impact the client’s access and engagement in services. The methods used to accomplish this goal may include: 
  • Developing strategies to improve attendance at mental health, substance use and primary care appointments, including attending initial appointments with the client
  • Complete referral and aid in service linkages that will address needs in the client’s life
  • Developing and completing a thorough review of the service client’s crisis plan
  • Working with the client to understand the potential benefit of the services that will be helpful and help the client achieve their recovery goals
  • Promoting and developing wellness activities
  • Modeling strategies and behaviors that will promote successful engagement in the health care delivery system
  • Supporting coordination of care and referrals with the clients with complex and/or emergent needs for support.
  • Promoting enrollment into Health Home Care Management and/or Home and Community Based Services (HCBS) as eligible.
  • Support client in the development of skills to improve self-advocacy.
• The impact of such a role may include:
  • Keeping people out of hospital and emergency rooms by supporting well-care connections and utilization of services before needs are emergent.
  • Improving quality of life
  • Promoting better health for the whole person
  • Offers support in moving towards recovery goals through care coordination activities.

Client Follow Up:

• Provide phone and face-to-face follow-up to clients and service providers.
• Create supportive relationships with each service provider and provide care coordination as well as education on the role and services available through the project.
• Understand the barriers clients are facing and ensure that strategies have been put in place to help clients successfully navigate these barriers and connect with the services they need.
• Support CCBHC related work activity through the Alert Manager to provide outreach and engagement services to identified clients.  Care Coordinator may be responsible for some alert management and data support.
• Coordination includes providing status updates on engagement status and reviewing potential next steps to ensure that a clear plan is in place for each client.
• Assist with documentation of all outreach and engagement efforts for client and/or service providers and provide reports of follow up to CCBHC Team.

Support Practice Change and Education:

• Provide feedback (both written and verbal) regarding what has been learned from the outreach and engagement process as requested.
• Provide project updates during staff meetings within the context of Lessons Learned: What is Working (when alerts are received).

Minimum Qualifications:

• HS Diploma/GED required, Associate’s Degree Required in Health Care Related Field preferred
• Minimum 1 year related experience, preferably in Behavioral Health
• Ability to establish supportive client relationships
• Ability to perform duties in a stable, consistent, and predictable manner
• Valid NYS Driver’s License in good standing
• Other Skills/Knowledge and Experience
• Excellent written and verbal communication skills.
• Demonstrated ability to communicate effectively and work cooperatively with culturally diverse persons, staff and multiple service provider agencies.
• Knowledge of local behavioral health system and social determinant supports.
• Ability to multi-task, have good problem solving and time management skills and the ability to remain calm in a crisis.
• MS Excel experience and skill in data collection and entry.