Behavioral Health Transition Of Care Manager

This position is for the MORGANTOWN FAIRMONT and CLARKSBURG AREA

The Transitional Care Manager (TCM) will coordinate care provided to members receiving high density behavioral health and co-occurring health services. The TCM will be deployed from a home office, but will spend time in identified behavioral health units exemplified by substance use disorder residential facilities, crisis stabilization units and acute inpatient psychiatric care units. The primary responsibility of the TCM will be to provide and assist with transitional services for members receiving care in intensive care facilities as well as high risk THP members in the community, identified via current data analytics, referrals from the Interdisciplinary Care Team for Behavioral Health and referrals from The Health Plan's Care Managers/UM staff. The TCM will attempt to establish relationships in the community with providers and members in order to assist the member to move from high density intensive episodic services to continuous, coordinated community care. The TCM will meet with members and providers on a face to face basis in order to establish rapport and build relationships so that other case management, utilization management and transitional efforts can be more effective. The TCM will refer the member to other THP care managers for longer term care as soon as certain initial objectives are met.

Required:

• Bachelor's degree in relevant field (nursing, social work, psychology, etc.).

• Minimum of two years experience in health and/or behavioral health direct care arenas.

• Familiarity with community resources for health and for social determinants of health.

• Familiarity/experience with Microsoft Office Programs (Word, Excel, Outlook).

• Valid driver's license and reliable transportation.

• Able to travel locally on a regular basis, no overnights.

• Excellent verbal and written communication skills.

Desired:

• Familiarity with the interdisciplinary team process.

• Case management experience.

Responsibilities:

• Develop mutually trusting relationships with the facility clinical teams;

• Ensure that the information exchange between provider and UM is accurate and comprehensive;

• Share information available regarding the member history with the clinical team as necessary and appropriate;

• Develop a relationship with the member on a face to face basis and begin to create a person centered discharge plan soon after admission, in conjunction with the facility team;

• Assist the member to complete Health Risk Assessments including assessment of social determinants of health and begin to create a short term set of objectives that addresses basic health promotion and prevention as well as behavioral health;

• Maintain telephonic engagement with the member 60 days post discharge in order to complete mutually agreed short term transitional health, behavioral health and socioeconomic objectives;

• Perform warm hand off by telehealth to center based health navigators or complex care managers if the member continues to be engaged in the case management relationship and has additional or continuing need for assistance at the end of the transitional period;

• Assist the member in applying for various community benefits and with obtaining needed documents such as social security cards, birth certificates, etc., if possible within the time line;

• Assist the discharge planner with appointment linkages and transportation;

• Help to arrange a discharge disposition/housing when necessary;

• Assist the member with initial negotiation of medical practices and information/forms;

• Maintain a relationship with the member for a time limited period post discharge to amplify member adherence and smooth transitions;

• Document member progress in THP record keeping systems.