Health Home Care Manager (Health Home Care Partner)

Eliot's behavioral health program is seeking an energetic, empathic, Care Manager to support members in the coordination of medical, behavioral health and Social Determinants of Health (SDOH) needs. The ideal candidate will have a strong commitment to mental health recovery, substance abuse disorders and the coordination of integrated care. Additionally, candidate will possess strong time-management, organizational and communication skills allowing for some work related tasks to be completed remotely.

Eliot's One Care Health Home program is an innovative Care Management approach for members with complex medical, behavioral health, and social needs who are dual eligible, having both Masshealth and Medicare benefits.

Responsibilities:

• Responsible for coordination of annual Person-Centered Care Plan (PCCP), coordination of interdisciplinary Member care teams, manager care transitions, and post-discharge follow-up where indicated, track and ensure documentation of Member's centralized record is current.
• Document all coordination activities and coordinate authorizations with CCA Clinical Operations Team.
• Provide rotating 24/7 On-call coverage.
• Outreach and engage member as soon as possible
• Partner with the member to develop and implement person-centered care plan; ensure member and key interdisciplinary team members receive a copy of care plan
• Connect members with needed services in alignment with a person-centered care plan
• Provide CCA Transitions of Care team with relevant info for admitted members to support inpatient care and discharge planning •< 48-hour post-discharge follow up visit to support the transition back to home/community •< 7-day post psych hospitalization visit by licensed BH clinician Interdisciplinary care team
• Convene interdisciplinary care team and coordinate activities to ensure integration
• Promote hope and empowerment through meetings and support with individuals.
• Provide transportation/ mobility resources that enable enrollees to fully participate in medical and community resource appointments and provide transportation when necessary.

Qualifications:

Must have a bachelor's degree or master's degree in psychology, social work or related field with three years direct experience in Care Management or Case Management or must be a Certified Peer Specialist or Certified Recovery Coach. May substitute one year of experience with a college degree in the human services field if a Peer Specialist or Recovery Coach. Must have a strong commitment to mental health recovery, substance abuse disorders, care coordination, and wellness. Must have skills to establish supportive relationships with persons with severe and persistent mental illnesses, individuals with substance abuse disorders, and those with complex medical conditions. Must have valid drivers license

Schedule: Monday-Friday 9am-5pm

Location: Primarily remote with options to work in Saugus offices. Some travel required for face-to-face meetings. Mileage reimbursed

Eliot is committed to identifying and dismantling barriers that prevent people with marginalized racial identities from actualizing their full employment potential, assuming leadership roles, or from fully engaging at all levels in the workplace.