Integrated Care Clinical Manager - BH - Pittsfield, MA

$80,000 - $120,000 / year

Job Summary:

The Integrated Care Clinical Manager - BH - Massachusetts is a community based BH Clinician responsible for providing monitoring, follow-up and clinical care management to dually eligible enrollees with complex medical, behavioral and social care needs. This position focuses on integrating health services and community resources to coordinate enrollee care for improve health outcomes and enhanced quality of life.

Essential Functions:

Engage with the enrollee in their homes and other community settings to establish an effective, complex care management relationship, while considering the cultural and linguistic needs of each member.
Function as a liaison between healthcare providers, community resources, and enrollees to ensure seamless communication and care transitions.
Perform required assessments on a timely basis, including but not limited to Comprehensive Assessment, MDS-HC (or successor) Functional Assessments, and Crisis and Risk Assessments
Engage enrollees in care plan development and implementation, providing routine updates as the enrollee’s status changes
Lead the interdisciplinary care team (ICT) and collaborate with peers both internal and external to the organization, to create holistic care plans that address medical and non-medical needs.
Oversee enrollee utilization of long-term services and supports, ensuring appropriate systems are in place for enrollees to remain in the location of their choice
Assist members in accessing community resources, including housing, transportation, food assistance, and social services.
Educate members about their benefits and available services under both Medicare and Medicaid.
Provide education to members and their families about managing chronic conditions, medication adherence, and preventive care.
Promote healthy lifestyle choices and self-management strategies.
Assist enrollees in preventative health strategies, including gap closure
Follow up with members after hospitalizations or significant health events to ensure continuity of care and prevent readmissions.
Work closely with primary care physicians, specialists, and other healthcare providers to coordinate care and share relevant information.
Coordinate with community-based organizations, other stakeholders/entities, state agencies, and other service providers to ensure coordination and avoid duplication of services.
Advocate for the needs and preferences of enrollees within the healthcare system.
Evaluate member satisfaction through open communication and monitoring of concerns or issues.
Regular travel to conduct member, provider and community-based visits as required
Report abuse, neglect, or exploitation of older adults and adults with disabilities as a mandated reporter as required by State law.
Adherence to NCQA and Care Management standards
Perform any other job related duties as requested.

Education and Experience:

Master's degree in social work or mental health counseling and independent license required
A BH Clinician with the ability to independently serve people with complex medical, behavioral, and social needs. required
Prior experience in care coordination, case management, or working with dual-eligible populations preferred
Medicaid and/or Medicare managed care experience preferred
Clinical Field / Community Based Training is a Plus

Competencies, Knowledge and Skills:

Intermediate proficiency level with Microsoft Office, including Outlook, Word and Excel.
Understanding of Medicare and Medicaid programs, as well community resources and services available to dual-eligible beneficiaries.
Strong interpersonal and communication skills to effectively engage with members, families, and healthcare providers
Ability to manage multiple cases and priorities while maintaining attention to detail.
Adhere to code of ethics that aligns with professional practice.
Awareness of and sensitivity to the diverse backgrounds and needs of the populations served
Decision making and problem-solving skills.
Ability to function independently and effectively as part of an interdisciplinary team
Strong and effective communication skills, both written and verbal
Strong interpersonal and customer relations skills
Strong customer service skills

Licensure and Certification:

Licensed Clinical Social Worker (LCSW), Licensed Independent Clinical Social Worker (LISCW), or a Licensed Mental Health Counselor (LMHC) required
Case Management Certification is highly preferred
Must have valid driver's license, vehicle and verifiable insurance. Employment in this position is conditional pending successful clearance of a driver’s license record check. If the driver’s license record results are unacceptable, the offer will be withdrawn or, if employee has started employment in position, employment in this position will be terminated
To help protect our employees, members, and the communities we serve from acquiring communicable diseases, Influenza vaccination is a requirement of this position. CareSource requires annual proof of Influenza vaccination for designated positions during Influenza season (October 1 – March 31) as a condition of continued employment. Employees hired during Influenza season will have thirty (30) days from their hire date to complete the required vaccination and have record of immunization verified.
CareSource adheres to all federal, state, and local regulations. CareSource provides reasonable accommodations to qualified individuals with disabilities or medical conditions, sincerely held religious beliefs, or as required by state law to enable the employee to perform the essential functions of the position. Request for accommodations will be completed through an interactive review process.

Working Conditions:

This is a mobile position, meaning that regular travel to different work locations, including homes, offices or other public settings, is essential. Will be exposed to weather conditions typical of the location and may be required to stand and/or sit for long periods of time. Must reside in the same territory they are assigned to work in; exceptions may be considered, due to business need May be required to travel greater than 50% of time to perform work duties. Required to use general office equipment, such as a telephone, photocopier, fax machine, and computer Flexible hours, including possible evenings and/or weekends as needed to serve the needs of our members
Must live within commutable distance to the Commonwealth of Massachusetts
Over 50% (Mobile) Routine travel required

Compensation Range:

$80,000 - $120,000

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Salary

Organization Level Competencies

Fostering a Collaborative Workplace Culture
Cultivate Partnerships
Develop Self and Others
Drive Execution
Influence Others
Pursue Personal Excellence
Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.

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Brand=Commonwealth Care Alliance

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$115,494 - $192,328 / year

Description Title - Nurse Practitioner Manager, Palliative Care at Home - Mount Sinai Home Health - Full Time - Day Palliative Care at Home, part of Mount Sinai at Home, provides home based palliative symptom assessment, treatment and ongoing goals of care discussions for patients and families facing advanced illness. The full clinical team is comprised of CHWs, NPs, nurses, social workers and physicians. The team works in collaboration with patients’ healthcare teams to provide high quality evidence based complex palliative care and chronic care management and is designed to improve symptoms and QOL, reduce caregiver burden, reduce unnecessary inpatient utilization, and facilitate hospice when appropriate. Nurse practitioners will be responsible for the symptom management of chronically/terminally ill patients within an interdisciplinary team environment. This role will provide disease process and trajectory education to the team, patients and families. 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When you join us, you become part of Mount Sinai’s unparalleled legacy of achievement, education, and innovation as we work together to transform healthcare. We encourage all team members to actively participate in creating a culture that ensures fair access to opportunities, promotes inclusive practices, and supports the success of every individual. At Mount Sinai, our leaders are committed to fostering a workplace where all employees feel valued, respected, and empowered to grow. We strive to create an environment where collaboration, fairness, and continuous learning drive positive change, improving the well-being of our staff, patients, and organization. Our leaders are expected to challenge outdated practices, promote a culture of respect, and work toward meaningful improvements that enhance patient care and workplace experiences. We are dedicated to building a supportive and welcoming environment where everyone has the opportunity to thrive and advance professionally. Explore this opportunity and be part of the next chapter in our history. About the Mount Sinai Health System: Mount Sinai Health System is one of the largest academic medical systems in the New York metro area, with more than 48,000 employees working across eight hospitals, more than 400 outpatient practices, more than 300 labs, a school of nursing, and a leading school of medicine and graduate education. Mount Sinai advances health for all people, everywhere, by taking on the most complex health care challenges of our time — discovering and applying new scientific learning and knowledge; developing safer, more effective treatments; educating the next generation of medical leaders and innovators; and supporting local communities by delivering high-quality care to all who need it. 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Ensures clinical education programs are aligned with CMS Triple Aim framework: improving the patient’s experience of care (including quality and satisfaction), improving the health of populations, and reducing the per capita cost of healthcare. Ensures clinical education programs address patient/member centered needs. Identifies and communicates protocols and standards of care for a cultural and demographic diverse patient population; provides education intervention guidelines based on these population health needs. Collaborates with medical leadership to ensure orientation and ongoing professional meet the needs of medical and advance nurse practitioners staff, and other clinicians. Manages implementation so such programs. Ensures that development and delivery of programs meet the strategic objectives of specific programs. Ensures all clinical education programs are in accordance with standards of nursing practice, state and federal regulations and VNS Health policies and procedures. Reviews program specific educational program outcomes and program evaluations to determine areas for improvement and makes recommendations for change and/or new programs for clinical education as appropriate. Presents improvement strategies to department leadership. Trains and/or oversees training of new and/or current Nurse Practitioners and Physicians, which includes pre-admission F2F visits, assessment, diagnosis, ordering and interpreting appropriate tests, and prescribing appropriate pharmacologic and non-pharmacologic treatment modalities and DME. Collaborates with interdisciplinary team members and providers regarding health care recommendations for patients. Trains and/or oversees training of new and current staff in VNS Health philosophy, policy, standards, procedures, documentation, models for service delivery and efficient, productive, cost-effective work processes. Monitors and evaluates performance of newly hired staff and staff referred on for remedial or additional training. Counsels, disciplines, terminates or extends probation for staff based on performance during introductory, probationary or training period. Designs new and modifies existing educational curriculum and training materials to ensure staff has current knowledge and competencies to meet program contractual and regulatory compliance. Conducts educational needs assessment in collaboration with operations staff to identify learning needs among staff. Analyzes and utilizes assessment data to plan for program educational sessions. Develops education programs such as workshops and/or group learning activities; follows up to ensure programs are effectively implemented. Identifies performance issues and develops performance improvement plans for tenured employees in collaboration with program management. Evaluates competency and performance in conjunction with program management. Reviews and evaluates clinical orientation and ongoing educational program outcomes to determine areas for improvement and recommends changes to current orientation program as appropriate. Participates in the development of revised programs and/or materials. Communicates ongoing e-learning opportunities. Evaluates e-learning usage and effectiveness; identifies opportunities for distance learning. Analyzes course evaluations in order to evaluate effectiveness of training sessions and to implement improvements. Participates in the development of annual clinical education strategic goals and objectives. Utilizes resources and practices sound fiscal responsibility; provides input for the development of the department budget. Monitors expenditures and ensures compliance with budgetary constraints. Collaborates with Quality department in the development of and implementation of education related training programs. Ensures program content is presented in a manner that promotes learning and enables trainees to meet competency requirements. Demonstrates services excellence and creates and implements education and training programs which are centered on the goals and strategies of VNS Health. Performs other supervisory related duties and projects as assigned. Participates in special projects and performs other duties as assigned. Qualifications Licenses and Certifications: Current license and registration to practice as a Nurse Practitioner in New York State required Certification in Nursing Education preferred Education: Master's Degree in nursing required PhD in nursing preferred Work Experience: Minimum four years of clinical nursing experience required Minimum two years of advanced practice nursing/Nurse Practitioner experience required Experience in a home care, palliative or hospice setting preferred Minimum of two years of experience in education and training required Knowledge of health care delivery systems, patient care, care coordination, and clinical processes required Experience assessing and designing clinical education programs preferred Experience in a health care setting in a teaching capacity with an understanding of adult education and learning processes preferred Effective oral and written communication, presentation, analytical, coaching and organizational skills required Knowledge of computer applications required Pay Range USD $98,200.00 - USD $130,800.00 /Yr. About Us VNS Health has been committed to meeting the needs of New Yorkers for over 130 years. We’re one of the largest nonprofit home- and community-based health care organizations in the country, and today, more than 11,500 team members work together to make a difference in the lives of more than 99,000 patients and members on any given day.