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MHSU Care Manager

- Fulltime  

MHSU Care Manager

Position Description Summary:

The Mental Health/Substance Use MH/SU Care Manager is responsible for providing proactive intervention and coordination of care to eligible members identified as Special Health Care Needs, Complex Care Management or High-Risk High-Cost populations to ensure that these individuals receive appropriate assessment and services. The MHSU Care Manager works with the member and care team to alleviate inappropriate levels of care or care gaps through assessment, multidisciplinary team care planning, linkage and/or coordination of services across the MH/SU/IDD and other healthcare network(s) with existing or new care team members. MHSU Care Managers support and may provide clinical transition planning assistance to local hospitals and tracks individuals discharged from state and community hospitals to ensure they follow up with aftercare services and receive needed assistance to prevent further hospitalization. This is a mobile position with work done in a variety of locations. The MHSU Care Manager may work with members in their home communities. The MHSU Care Managers also works with other company staff, members and family members, providers as well as community stakeholders. Essential job functions of the MHSU Care Managers include, but may not be limited to:

  • CM Platform basics
  • Outreach & Engagement
  • Release of Information practices
  • Health Risk Assessment
  • Medication List and Continuity of Care process
  • Care Planning
  • Interdisciplinary Care Team and Ongoing Care Management

Note: This position requires access to and use of confidential healthcare information or protected health information (PHI) as described in laws addressing patient confidentiality, including, but not limited to, the federal HIPAA law, the Confidentiality of Alcohol and Substance Abuse Patient Records law, 42 CFR Part 2, and various state laws. As such, the individual filling this position shall be required to be trained regarding such laws and shall be required to observe those laws in his/her capacity as an employee. The individual filling this position shall also sign a confidentiality statement as an employee of the company.

Essential Duties and Responsibilities: List in order of importance and Percentages equal to 100%

30 % Clinical Assessment:

MHSU Care Manager meets with members to conduct a comprehensive bio-psycho-social assessment in order to gather information on their overall health, including behavioral health, developmental, medical, and social needs. The Health Risk Assessment (HRA) encompasses a comprehensive assessment addressing social determinants of health, mental health history and needs, physical health history and needs, intellectual/developmental disabilities, activities of daily living, access to resources, and other areas to ensure a whole-person approach to care. MHSU Care Manager may administer the PHQ-9, GAD, CRAFFT, ACES, LOCUS/ CALOCUS, and other assessments based on member’s clinical needs and scores are calculated and reviewed allowing MHSU CM to provide specific education and self-management strategies as well as linkage to appropriate therapeutic support. The assessment process includes reviewing and transcribing members’ current medication and entering into Company's Care Management platform to ensure the medication aspects of the member's health and care are addressed according to Company procedures.

The MHSU Care Manager uses the assessment to learn about the member's needs to assist the member and their team in planning for their care, prioritizing goals that to help them live the life they want in the community of their choice. MHSU Care Managers ensure members of the care team are involved in the assessment as indicated by the member and that other available clinical information is reviewed and incorporated into the assessment as necessary.

MHSU Care Managers are also responsible to review clinical assessments conducted by providers to ensure all areas of the member’s needs are addressed.

Assessments are completed at least annually, and anytime there is a significant life change or as indicated in Company policy.

40% Care Planning & Interdisciplinary Care Team

MHSU Care Managers use the assessment to create a person-centered care plan for members to help define what is important to members for their health. Care Plans are created based on information collected in the assessment process. MHSU CM assists members in refining and formulating treatment goals, identifying interventions, measurements, and barriers to the goals. MHSU CM works in an integrated care team including an RN and pharmacist along with the member to address needs and goals in the most effective way. MHSU CM and members solicit input from the care team and monitor progress. MHSU Care Managers ensure Care Plans include specific services to address mental health, substance use or intellectual/developmental disability, medical and social needs as well as personal goals.

MHSU Care Managers work with members and care teams to ensure care plans are developed at least once a year or anytime there is a significant life change.

MHSU Care Managers ensure that members/guardians have the opportunity to decide who they want at the care team meeting and coordinates and may facilitate the team meeting where member Care Plan is discussed and reviewed. The MHSU Care Manager ensures that the assessment, care plan and other relevant information is provided to the care team as indicated in Company policy.

Other elements of Care Planning include:

· Risk Management- Proactively ensures that individuals identified as a Special Needs enrollee that have treatment needs or require regular monitoring have a Behavioral Health Clinical Home and a Medical Home.

· Ensures that a Person-Centered Plan (PCP) is developed by a Behavioral Health Clinical Home or, if necessary, by the Care Manager to meet urgent needs and to access care for the individual.

· Executes skills in Motivational Interviewing (MI), as well as Screening, Brief Intervention, and Referral to Treatment (SBIRT), Solutions-Focused Brief interventions.

· Identifies gaps in services and intervenes to ensure that the individual receives appropriate care.

· Measures results of intervention and treatment, including reduction in high-risk events and inappropriate service utilization.

· Ensures that services for the individual are coordinated across the Company system and with other systems, including primary care.

· Provides clinical discharge planning assistance to local hospitals and tracks individuals discharged from state and local hospitals to ensure they follow up with aftercare services and receive needed assistance to prevent further hospitalization.

· Crisis planning with member and care team. MHSU Care Managers create a care management crisis plan which is separate but complimentary to the behavioral health provider’s crisis plan. MHSU CM collaborates with members to develop a Crisis Plan that is tailored to their needs and desires. The MHSU Care Manager ensures the crisis plan includes problem definition, physical/cognitive limitations, health risks/concerns, medication alerts, baseline functioning, signs/symptoms of crisis (triggers), de-escalation techniques. Provide crisis intervention, coordination, and care management if needed while with members in the community.


25% Collaboration:

Serves as a collaborative partner in identifying system barriers through work with community stakeholders. Manages and facilitates Child/Adult High-Risk Team meetings in collaboration with DSS, DJJ, CCNC, school systems, and other community stakeholders as appropriate. Works in partnership with other Vaya departments to address identified needs within the catchment. MHSU CM may participate in cross-functional clinical and non-clinical meetings and other projects to support the department and organization. Participate in routine multidisciplinary huddles including RN, Pharmacist, M.D. to present complex clinical case presentation and needs, providing support to other CCM’s and receiving support and feedback regarding CCM interventions for clients’ medical, behavioral health, intellectual /developmental disability, medication, and other needs. MHSU CM participates in other high-risk multidisciplinary complex case staffing as needed to include Company Medical Director, Utilization Management, Provider Network, and Complex Care Management leadership to address barriers, identify need for specialized services to meet client needs within or outside the current behavioral health system.


Other duties as assigned.

Supervisory Responsibilities:



Education and Experience:

Master’s Degree in Human Service-related field (such as Psychology, Social Work, etc.) is required, along with at least two years of post-degree progressive experience providing similar services to the population served. Additionally, valid licensure or certification in profession (social work, counseling, or psychology) is required.

Mental/Physical Demands:

Person in this position is required to have close visual acuity to perform activities that include viewing a computer terminal; and extensive reading. Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists, and fingers. Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time.

Knowledge, Skills and Abilities:

Employee will participate in and maintain Care Management and Company trainings and proficiencies as required.

A high level of diplomacy and discretion is required to effectively negotiate and resolve issues with minimal assistance. This will require exceptional interpersonal skills, highly effective communication ability, and the propensity to make prompt independent decisions based upon relevant facts. Problem-solving, negotiation, arbitration and conflict resolution skills are essential to balance the needs of both internal and external customers. Must be highly skilled at shifting between macro and micro level planning, maintaining both the big picture, and seeing that the details are covered.

MH/SU Care Managers must exhibit an extensive understanding of the Diagnostic and Statistical Manual of Mental Disorders (current version) and have considerable knowledge of the MH/SU/DD service array provided through the network of Vaya providers. Additional knowledge in Vaya Medicaid B and C waivers and accreditation is essential.

The employee must be detail-oriented, able to organize multiple tasks and priorities, and to effectively manage projects from start to finish. Work activities quickly change according to mandated changes and changing priorities within the department. The employee must be able to change the focus of his/her activities to meet changing priorities.

Training, learning, and proficiency are tracked through the Care Management Training Matrix and any other required means. Training may be delivered in a variety of methods and forums. MHSU Care Managers must understand the following areas, in addition to other required trainings:

· BH I/DD Tailored Plan eligibility and services

· Whole-person health and unmet resource needs (ACEs, Trauma, cultural humility)

· Community integration (Independent living skills; transition and diversion, supportive housing, employment, etc.)

· Components of Health Home Care Management (Health Home overview, working in a multidisciplinary care team, etc.)

· Health promotion (Common physical comorbidities, self-management, use of IT, care planning, ongoing coordination)

· Other care management skills (Transitional care management, motivational interviewing, Person-centered needs assessment and care planning, etc.)

· Serving members with I/DD or TBI (Understanding various I/DD and TBI diagnoses, HCBS, Accessing assistive technologies, etc.)

· Serving children (Child- and family-centered teams, Understanding of the “System of Care” approach)

· Serving pregnant and postpartum women with SUD or with SUD history

· Serving members with LTSS needs (Coordinating with supported employment resources

MHSU Care Managers should be proficient in the aforementioned essential job functions. Job functions with higher consequences of error may be identified, and proficiency demonstrated and measured through job simulation exercises administered by the supervisor where a minimum threshold is required of the position.

In addition, MHSU CM must have a thorough knowledge of standard office practices, procedures, equipment, and techniques and have intermediate to advanced proficiency in Microsoft office products (Word, Excel, Power Point, Outlook, Teams, etc.)


Valid licensure or certification in profession (social work, counseling, or psychology) is required.



Driving on Company Business:

This position requires driving a personal vehicle for Company Business in accordance with 2995 Expense Reimbursement policy and 2498 Driving on Company Business.

Decision Making/Consequences of Error:

Decisions result in clients either receiving or not receiving appropriate Services or appropriate referrals for higher-level assistance as needed.

American’s with Disabilities Act (ADA):

A request for accommodation under the American’s with Disabilities Act (ADA) can be discussed with Human Resources and the process for ADA can be found in Policy 2973 Americans with Disabilities Act.