Behavioral Health ECM Service Coordinator III

JOB TITLE: Licensed Behavioral Health ECM Service Coordinator III

PROGRAM: Cal Aim Programs (Enhanced Care Management and Community Supports)

REPORTS TO: Program Director

HOURS: 8:00am-4:30pm

CLASSIFICATION: Exempt 

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. Cal Aim 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 ILOS Community Supports Program provides housing navigation services and retention services to homeless and formerly homeless adults and now requires clinical support for enrollment and extension.

The licensed CalAIM Behavior Health Care Coordinator III (BHSC III) 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 BHSC III will provide case management services and individual therapy. and a concise behavioral curriculum based on assessment, evaluations, and healthcare screenings. The BHSC III will ensure alignment between healthcare assessments and service plan goals and action steps. The BHSC III will possess skills and knowledge to provide support and guidance to CalAIM program care coordinators serving Monterey County. The BHSC III 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]. Direct staff support and some telehealth can be remote)

Benefits and What We Offer:

• Opportunities for growth and professional development.
• Generous paid time off (13 paid holidays, 10 days of EPTO, 12 sick days).
• Competitive salary and benefits package. Health, dental, vision, Aflac, and life insurance $25,000.00
• 403(b) retirement plan available on the first day of work. After working 1000 hours, Step Up matches 3% of the 6% the employee contributes.

ESSENTIAL DUTIES: The BHSC III is responsible for working effectively with and as part of the ECM interdisciplinary team to provide high quality, effective care management to ECM members and ILOS members. The BHSC III 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. The BHSC III will also provide clinical oversight to multiple Step-Up Programs, including signing service plans, auditing healthcare assessments, and ensuring that members’ most pressing needs are reflected in each care plan.

Direct Service and Support

• BHSC II may provide: 
  • Crisis response
  • Suicide ideation and self-harm interventions.
  • Grief counseling
  • Diagnostic Support
  • Therapy
  • Supervision for MSW staff and interns.
• Utilize 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.
• Utilize evidence-based practices when supporting members in therapeutic and community-based capacities.
• Provide informal and formal workshops and trainings on evidence-based practices to Monterey County staff across multiple programs.
• Engage with members in field-based and telehealth settings, modeling Step-Up’s core values in practice.
• Assist with the coordination of medical and behavioral health access issues with Step Up’s FSP Program, PCP offices, specialists and ancillary services.
• Participate in STEP UP’S ECM team meetings and Cal Aim interdisciplinary meetings, helping to inform best practices, discuss wraparound supports and align service plan goals with action steps.
• Provide in-person and telehealth therapy services to members who are referred by Cal Aim case managers. Develop a therapeutic schedule that is consistent/aligned with member and programmatic needs.
• Collaborate on member care issues with other STEP-UP team participants during weekly systematic case conferences and consult with other clinical partners on advanced high acuity cases.
• Build and maintain a positive working relationship with other community partners and providers through various forms of communication.
• Model commitment to continuous quality improvement by engaging in quality assurance initiatives and meeting DHCS recommendations/standards.
• Any other duties as required to ensure Cal Aim operations are successful.

Documentation and Data Collection

• Complete and become proficient in each members 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 compliance.
• Ensure completion of the Comprehensive 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). \
• Submit correct ICD-10 codes post diagnosis for Cal Aim enrollments and extensions.
• Submit 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.
• Provide Clinical Supervision to interns at Step Up in Monterey County Programs.

MINIMUM QUALIFICATIONS

 SKILLS: Highly skilled interpersonally, with excellent relationship skills. 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: LMFT, LCSW, or LPCC license is required. Bilingual Required. A valid California driver’s license and clean driving record. A reliable vehicle and valid automobile insurance is mandatory as automobile travel is required across Monterey County in 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