JOB SUMMARY:

Under the general supervision of the Site Manager, this position is responsible for working effectively with, and as part of the CB-CME to provide high quality, effective care management to Health Homes Program (HHP) members. Care management is broadly defined, and can include 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 transitions of care, and facilitating the right care and the right time for the member. This position works collaboratively as part of the Community- Based Care Management Entity (CB-CME) team, members and families, and other professionals, in addition to working collaboratively with the designated PCP care team.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

1. Responsible for primarily working with a caseload of HHP Members with behavioral health needs.

1. Responsible for utilizing brief behavioral health therapeutic interventions as necessary to improve the Member's ability to manage their own health.

1. Provide formal and informal training and support for HHP Members on behavioral health conditions, including treatments and evidence-base for treatment.

1. Responsible for assisting Members with care coordination needs, including, but not limited to, the following:

1. a) Ensuring completion of the Complex Health Assessment (CHA) for all eligible HHP high risk Members

1. b) Assimilate CHA information into a Shared Care Plan (SCP)/Health Action Plan (HAP)

1. c) Communicate SCP with Member, approved family or caregiver and other Members of the care team

1. d) Participate in multi-disciplinary care team meetings to share information, update and inform care plan

1. e) Coordinate with internal and external health partners to support Member's comprehensive care needs

1. f) Participate and lead (as necessary) for care transition plan responsibilities.

1. g) Provide active, on-site support for Members and care team staff within the CB-CME

KNOWLEDGE, SKILLS AND ABILITIES:

• Highly skilled interpersonally, with excellent relationship skills. Knowledgeable and skilled in evidenced based communication such as Motivational Interviewing, or similar empathy based communication strategies. Highly skilled in interpersonal communication, including resolving conflict with co-workers. 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 community. Deep understanding and knowledge of mental health and substance use conditions, including both acute and chronic management of. Skillful in informally and formally sharing expertise. Awareness of the impact of unmitigated bias and judgement on health; commitment to addressing both. Bilingual (English/Spanish) preferred. 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 care, and new care management practices.

• Bilingual (English/Spanish) preferred.
• A high standard of professionalism and professional ethics and conduct is expected in speech, manner, attitude and appearance at all times.
• Possess strong interpersonal skills and ability to work well with others.
• Well-developed verbal and written communication skills and the ability to work cooperatively with divergent groups
• Must possess excellent customer service including verbal and written communication.
• Ability to deal effectively with changing situations and stressful environment.

• Ability to perform tasks related to physical activity to complete the responsibilities of the position.

• EXPERIENCE AND EDUCATION:

  • Minimum of (3) three years of experience performing or facilitating Behavioral Health services in a health clinic/psychiatric hospital medical facility, or health care clinic strongly preferred. Familiarity with Managed Care and discharge planning is preferred.
  • Experience working successfully within a team, and experience in developing and maintaining effective relationships with both clients and coworkers is mandatory. Experience in clinical services, both mental health and substance use preferred; experience in motivational interviewing and/or other evidenced based communication strategies highly preferred.
  • Masters in Social Work or a Marriage and Family Therapist Degree (MSW or MFT) and registered with the BBS obtaining hours for licensure required. A valid California driver's license, a reliable car, and valid automobile insurance are also required. IEHP will verify these requirements, as automobile travel within the Inland Empire required.

  ESSENTIAL FUNCTIONS:

  Physical Activities: Minimal physical activity; may include standing and repetitive motion.

  Commitment to Team Culture: The IEHP Team environment requires a Team Member to participate in the IEHP Team Culture. A Team Member demonstrates support of the Culture by developing professional and effective working relationships that include elements of respect and cooperation with Team Members, Members and associates outside of our organization.