Behavioral Health ECM Service Coordinator III

JOB TITLE: Behavioral Health ECM Service Coordinator III

PROGRAM: Enhanced Care Management

REPORTS TO: Program Director

HOURS: 8:00am-4:30pm

CLASSIFICATION: Exempt 

REQUISITION # 1664

SUMMARY:

The Enhanced Care Management (ECM) program, funded through California Advancing and Innovating Medi-Cal (CalAIM), is designed to efficiently coordinate supportive care for highly vulnerable and high-acuity adults experiencing homelessness or at risk of homelessness.  

ECM is focused on dismantling the traditional walls of healthcare, extending beyond hospitals and healthcare settings to the communities we serve. CalAIM works to improve healthcare case management services for individuals with complex physical and mental health needs.

The ECM program aims to meet members in their preferred environment and leverage existing community care management infrastructure to maximize member wellness and streamline services. The licensed CalAIM Behavioral Health Care Coordinator III (BHSC III) will work collaboratively as part of our integrated service delivery model and assess and maintain overall behavioral care needs for all enrolled individuals.

The licensed BHCC III will provide case management services and a concise behavioral health 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 the skills and knowledge to provide support and guidance to CalAIM program care coordinators serving Monterey County.

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 Step Up’s ECM interdisciplinary team to provide high quality, effective care management to ECM members. The BHSC III will provide field-based services including: outreach and engagement, engaging members in skilled therapeutic interactions, coordination of care, resource linkage, triage, crisis response and conflict management.  
• The BHSC III may also provide clinical oversight to the ECM Program, 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 III may also provide: Crisis response, suicide ideation and self-harm support, grief and abandonment support, and individual counseling.
• 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.
• 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 promote collaboration between the member and their health.
• Assists with the coordination of medical and behavioral health access issues with PCP offices, specialists, and ancillary services.
• 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.
• 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 behavioral health providers.
• Build and maintain positive working relationships with other community partners and providers through various communication channels.
• 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.
• Ensure completion of the Comprehensive Health Assessment (CHA) for all eligible ECM high-risk members within the specified timeframe. Communicate PHQ-9, GAD-7, and behavioral health assessments with members, approved family or caregivers, and other members of the care team each month.
• Review and maintain clinical assessments and specialized mental health assessments. 
• Medication review, reconciliation, and interaction, as well as regular physical health monitoring (including blood pressure readings, lab work, and nutrition) as needed. 
• Maintain documentation for each member contact as instructed and within the program timelines (within 48 hours, weekly, monthly, and quarterly). 
• Submit billable notes to provider portals, Step Up electronic health records (Welligent), and maintain members’ charts and profiles, systems, and portals within Step Up’s contracts. 
• Provide Clinical Supervision (if applicable) to interns at Step Up in Monterey County Programs. 

  SKILLS:

• Highly skilled in interpersonal interactions, with excellent relationship-building skills. Knowledgeable and skilled in evidence-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 judgment 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. Members must possess the skills to tolerate, manage, and effectively utilize a high level of ambiguity surrounding new team models, models of care, and care management practices.

QUALIFICATIONS:

• Bilingual Required.(English &Spanish)
• Must have LCSW, LMFT, or LPCC license and be registered with the CA BBS. 
• A valid California driver’s license and a clean driving record are required.
• A reliable vehicle and valid automobile insurance are mandatory as automobile travel is required across Monterey County in a personal or company vehicle.
• Step Up will verify these requirements. No findings on the (DOJ) Department of Justice background check.  
• Availability [3 days a week] and direct staff support (remotely)

EXPERIENCE: 

• Minimum three (3) years of experience in performing or facilitating behavioral health services in a 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