Behavioral Health ECM Service Coordinator II

JOB TITLE: Behavioral Health ECM Service Coordinator II PROGRAM: Enhanced Care Management REPORTS TO: Program Manager HOURS: 8:00am-4:30pm CLASSIFICATION: Exempt $70,000-$75,000 Annually REQUISITION NUMBER: 1664
SUMMARY: The Enhanced Care Management (ECM) program is funded through California Advancing and Innovating Medi-Cal (CalAIM) and is designed to efficiently coordinate supportive care for highly vulnerable/high acuity adults experiencing homelessness or at risk of homelessness. ECM is focused on dismantling the traditional walls of health care – extending beyond hospitals and health care settings to the communities we serve. CalAIM works to improve healthcare case management services for people with complex physical and mental health needs. The ECM program seeks to meet members in their preferred environment and leverage existing community care management infrastructure to maximize member wellness and streamline services. The CalAIM Behavior Health Care Coordinator II (BHCC II) will work collaboratively as part of our integrated service delivery model and will assess and maintain overall behavioral care needs for all enrolled individuals. The licensed BHCC II will provide case management services, and a concise behavior health curriculum based on assessment, evaluations, and healthcare screenings. The BHCC will ensure alignment between healthcare assessments and service plan goals and action steps. The BHCC II will possess skills and knowledge to provide support and guidance to CalAIM program care coordinators serving Monterey County. The BHCC II will critically analyze the social determinants of health and understand the root causes of health outcomes
Work Schedule: Hybrid (in-person office [3-days a week] and direct staff support, remotely)
ESSENTIAL DUTIES: The BHSC II is responsible for working effectively with and as part of the Step Up’s ECM interdisciplinary team to provide high quality, effective care management to ECM members. The BHCCII will provide field-based services including: outreach and engagement to members, engaging members in skilled therapeutic interactions to promote health behaviors, other behavioral health interventions within scope, coordination of care, resource linkages, working with other professionals and organizations in the community to ensure quality of care for members, seamless transition of care, and facilitating the right care at the right time for the members
Direct Service and Support

• BHSC II may also participate and not limited to:
  • Crisis response
  • Suicide ideation and self-harm
  • Grief and abandonment
  • Family breakdown
  • Referral services
  • Advocating services
• Utilize brief behavioral health therapeutic interventions as necessary to improve the member’s ability to manage their own mental health concerns and symptoms and to assist members with care coordination needs.
• Provide formal and informal training and support for ECM members on behavioral health conditions including evidence-based for treatments.
• Engage with members in person in a field-based setting in a manner that utilizes evidence- based approaches, such as Motivational Interviewing (MI)/Trauma Informed care (TIC), that promotes collaboration between the member and his or her health.
• Assists with the coordination of medical and behavioral health access issues with Step Up’s FSP Program, PCP offices, specialists and ancillary services.
• Represent the Step Up’s ECM when requested by the Program Director or as needed for clinical support and direction
• Participate in STEP UP’S ECM team meetings to share info update and inform care plan and care transition plan responsibilities, trainings committee meetings and other activities as needed or directly by the STEP UP’S ECM program
• Collaborate on member care issues with other STEP UP’S ECM team participants in weekly systematic case reviews and ad hoc case reviews and consult with nurse care manger and or behavioral health providers before taking any action that is clinical in nature.
• Model the highest ethical behavior in relationship with co-workers, supervisor, members, provider, and colleagues in the community and within Step Up’s ECM when discussing responsibility/sharing of tasks, effective resolving conflict as they arise and collaborating on member case discussions.
• Build and maintain a positive working relationship with other community partners and providers including by not limited to communication via in-person, over the phone, and through digital means, such as email and fax.
• Model commitment to continuous quality improvement by engaging in quality improvement initiative and projects such as by identifying and assessing gaps and by identifying, developing and testing new practices for improving the outcomes of the ECM program.
• Any other duties as required to ensure ECM operations are successful.

Documentation and Data Collection

• Complete and become proficient in each provider’s Electronic Health Record to ensure documentation is accurate and in compliance with regulatory requirements and accreditation standards. Maintain documentation for each contact as instructed and within the program timelines (weekly, monthly, and quarterly).
• Ensure the privacy and security of the PHI as outlined in Step Up’s policies and procedures relating to HIPAA complain including attending annual compliance training.
• Ensure completion of the Complex Health Assessment (CHA) for all eligible ECM high-risk members within specified timeframe. Communicate PHQ9, GAD7 and behavior health assessments with members, approved family or caregiver and other members of the care team each month.
• Review and maintain clinical assessments and specialized mental health assessments.
• Medication review, reconciliation and interaction, and physical health monitoring (blood pressure readings, lab work, nutrition, etc.) regularly/ as needed.
• Maintain documentation for each member contact as instructed and within the program timelines (within 48 hours, weekly, monthly, and quarterly).
• Submitting billable notes to provider portals, Step Up electronic health records (Welligent) and maintaining member’s charts and profiles, systems, and portals within Step Up’s contracts.
• Report emergencies, urgent care needs, crisis, etc. to Step Up management necessary documentation.

MINIMUM QUALIFICATIONS
SKILLS: Highly skilled interpersonally, with excellent relationship skills including resolving conflict with co-workers. Knowledgeable and skilled in evidenced based communication such as Motivational Interviewing or similar empathy-based communication strategies. Able to sufficiently engage members and providers on the phone, including developing effective relationships that are phone based Understanding of and sensitivity to multi- cultural communities. Deep understanding and knowledge of mental health and substance use conditions, including self-managed philosophies and practices Awareness of the impact of unmitigated bias, and judgement on health; a commitment to addressing both. Must be able to work as a member of a highly autonomous team, executing job duties and making skillful decisions as an independent team. Must have skills to tolerate, manage and make effective use of a high level of ambiguity around new team models, new models of are, and new care management practices
QUALIFICATIONS: Must have ASW License minimum. A valid California driver’s license and clean driving record. A reliable vehicle and valid automobile insurance is mandatory as automobile travel is required in the Inland Empire either by personal or company vehicle. Step Up will verify these requirements. No findings on (DOJ) Department of Justice background check
EXPERIENCE: Minimum three (3) experience of performing or facilitating behavioral health services in community clinic or health care delivery setting. Familiarity with Managed Care and discharge planning. Strong diagnostic skills and experience working with various social determinants of health and diverse populations (serious mental health illness, substance use disorder, homelessness, etc.)
SUPPLEMENTAL INFORMATION: Work with people experiencing homelessness whether on the streets, in shelters or other places of habitation or services, may present inherent challenges and difficulties such as: exposure to bed bugs or other infestations, unpleasant smells or odors, individuals who may have poor hygiene or unclean homes due to homelessness, mental health symptoms, or poverty. Additionally, in working with our members, employees may encounter instances of profanity, sexually explicit or derogatory language, or verbal or physical expressions of anger and trauma. Very rarely do these situations ever escalate to physical contact, and negative or derogatory communication patterns can often be negotiated successfully. All direct care staff are provided adequate training to develop skills to deescalate crisis situations that may arise and Step Up has established procedural safeguards for all employees to mitigate (but not eliminate) these inherent risks of employment
PHYSICAL REQUIREMENTS: While performing the duties of this job, the employee is regularly required to sit; use hands and fingers; handle or feel; reach with hands and arms; talk; and hear. The employee is frequently required to walk, balance, stoop, kneel, and/or crouch. The employee must occasionally lift and/or move up to 15 pounds. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception, and ability to adjust focus. Keyboard data entry required Step Up utilizes the principles of trauma-informed care and mental health recovery. These principles inform our Core Values of Hope, Wellness, Voice and Choice, Respect, and Collaborative Relationships. As representatives of Step Up, employees agree to adhere to these values in their interactions with members, colleagues, supervisors, and associated community members
STEP UP CORE VALUES
HOPE – We believe all people have the capacity for positive growth and change. We use hope to inspire and motivate ourselves, our members, our colleagues, and our community WELLNESS – We believe in promoting a culture that supports healthy and fulfilling lives. We use a supportive environment to foster well-being for ourselves, our members, our colleagues, and our community VOICE AND CHOICE – We believe in the right to choose and be heard. We use voice and choice to create meaningful outcomes and empowerment for ourselves, our members, our colleagues, and our community RESPECT – We believe in promoting interactions that are non-judgmental, transparent. We use respect to guide all of our words and actions with ourselves, our members, our colleagues, and our community COLLABORATIVE RELATIONSHIPS – We believe in forming partnerships to share resources, knowledge, and experiences. We use collaborative relationships to strengthen accomplishments for ourselves, our members, our colleagues, and our community
Step Up provides equal employment opportunities without regard to age, ancestry, color, creed, mental or physical disability, marital status, medical condition, national origin, race, religion, sex, sexual orientation, veteran status, or any other consideration made unlawful by federal, state, or local laws
STEP UP IS AN EQUAL OPPORTUNITY EMPLOYER