BH HARP Integrated Care Manager

MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health Hospitals, the largest public health system in the United States, MetroPlusHealth network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlusHealth has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.

Position Overview:

Empower. Unite. Care.

MetroPlusHealthis committed to empowering New Yorkers by uniting communities through care. We believe that Health care is a right, not a privilege. If you have compassion and a collaborative spirit, work with us. You can come to work being proud of what you do every day.

The BH HARP Integrated Care Manager develops, facilitates, and communicates a plan of care in partnership with the member, their assigned Health Home, primary caregiver, medical specialists, the primary and attending physicians, and various Mental Health and/or Substance Use Disorder providers. This position collaborates with the aforementioned parties to assess, plan, facilitate, and advocate for options and services to meet a member's medical and behavioral health needs through communication and available resources.

• Manage a caseload of HARP members with medical risk factors and those with high-risk medical diagnosis discharging out of inpatient admissions.
• Clinically assess members for acute physical health and behavioral health needs following inpatient admissions for medical reasons.
• Generating referrals to providers, community-based resources, and appropriate services and other resources to assist in goal achievement.
• Develop a formal plan of care for all services needed for the member.
• Notify physicians for any changes in member's plan of care. Follow up with assigned nurses for clinical updates to plans of care.
• Document IDT care coordination notes between both internal MetroPlusHealth staff and external health providers and caregivers.
• Attend and prepare for Interdisciplinary Care Team (ICT) meetings which will feature newly enrolled, frequently admitted, high utilizing at risk members.
• Assist members with the coordination of services from various settings as appropriate. Including facilitating discharge from acute setting and alternate settings. Provides Care Coordination throughout the continuum of care. Optimizes both the quality of care and the quality of life for the MetroPlusHealth members.
• Educate member on health-related conditions and support member in addressing gaps in health care through connection to direct care providers, resources and medications, as appropriate to members conditions.
• Documents in a comprehensive manner to ensure that all goals, interventions, and care coordination activities for each member in EMR system, and other applicable software programs, are complaint with professional standards and regulatory guidelines.
• Evaluate SDOH needs appropriately and assist connection to resources in member's community
• Contributes to MetroPlusHealth corporate goals through ongoing execution of member care plans and member goal achievement.
• Accountable to the HARP Medical Director.
• Conference cases with HARP Medical Director as outlined by Medical Director or other supervisory staff.
• Track health outcomes as required by HARP Medical Director or other supervisory staff.
• Performs other appropriate duties and participates in other special projects as assigned, including, but not limited to, audit review and preparation, quality improvement, community health education, facility/provider relations and marketing activities.

• Master's degree in healthcare or related field required
• 3-5 years of Medical and Behavioral Health (Serious Mental Illness & Substance Use Disorder) experience, preferably in an Inpatient Hospital; and
• 1-3 years Managed Care Case Management experience
• Working knowledge of NY State Health Home System and Plan of Care process
• Case Management Experience within the Integrated Collaborative Care Model Approach
• Previous history of conducting discharge planning and providing direct education around medical conditions
• Knowledge of Psyckes, E-Paces, HCS (UAS) MAPP, Microsoft Teams Video knowledge preferred.
• Medical Background & Bilingual preferred.

Licensure and/or Certification Required:

• Current valid unrestricted NY State License as LCSW, LMSW, or LMHC or RN required

Professional Competencies:

• Integrity and Trust
• Customer Service Member FIRST Focus
• Superior Technical Computer skills (Microsoft Office, DCMS, Teams Video Application)
• Exceptional Organizational and Communication Skills
• Strong interpersonal and assessment skills, the ability to remain calm and poised with challenging members who often present as in a constant state of crisis.