MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.

Position Overview

The Children's Behavioral Health Care Manager (BH CM) works in the Children's Special Services Department and provides a hybrid approach, including utilization and case management, to support members aged 0-21 years with complex behavioral, medical, and/or developmental health issues. The Children's BH CM is responsible for conducting utilization and quality management activities in accordance with New York State and MetroPlusHealth Utilization Management policies and procedures for diversionary services including, but not limited to HCBS, AOT, and PROS. The Children's BH CM is also responsible for reviewing and approving Plans of Care and HCBS services in collaboration with the CSS Medical CMs and Foster Care Liaison, as indicated. The Children's BH CM works with Health Home Coordinators, LDSS/VCFA, and community providers to advocate for proper access to comprehensive services and continuation of care.

Job Description

• Performs telephonic review for diversionary and outpatient services using NYS criteria for HCBS services.
• Contributes to UM program goals and objectives by containing health care costs and promoting diversionary services to avoid unnecessary admissions by maintaining a high-quality medical delivery system through departmental UM procedures.
• Collects all pertinent clinical information and documents within our care and utilization management
• Promotes alternative care programs, research available options including eligibility for waivers programs, considers costs and appropriateness of patient placement in collaboration with health plan members.
• Communicates with Medical Director regarding all outpatient/diversionary requests for health care services that do not meet medical necessity or appropriate level of care and out of network transfer issues.
• Recommends, coordinates, and educates providers regarding alternative care options.
• Educate providers on medication and treatment compliance while also promoting the use of Long Acting Injectables
• Enlist existing provider network in promoting first episode psychosis treatment.
• Educate providers to alternate treatment services being promoted by Health + Hospitals in lieu of Inpatient Detox.
• Attends and prepares for Integrated Clinical Rounds meetings which focus on newly enrolled, frequently admitted, high utilizing at-risk children/youth.
• Maintains an active role in assuring the continuity of care for all members who have been admitted through collaboration with BH UM CM, early discharge planning, and working with hospital Social Worker discharge planning staff, Health Homes, and community providers.
• Identifies potentially catastrophic, high-risk medical and behavioral cases, and Transitioning Aged Youth (TAY) and coordinates with Children's Nurse CM and Foster Care Liaison, as indicated, to provide an integrated approach to case management.
• Identifies and communicates all potential quality of care concerns to Director in a timely manner.
• Contributes to MetroPlusHealth corporate goals through ongoing active team participation, offering input and assistance with development and delivery of education and trainings.
• Performs other appropriate BH UM/CM duties as assigned by Medical Director, Director of Children's Special Services, and/or the BH HARP Department Management and participates in other special projects, including, but not limited to, monthly audit review and preparation, quality improvement, community health education, facility/provider relations and marketing activities.
• Promotes a multigenerational approach to care management and provide education, referrals, and coaching to members' families to foster a supportive environment.
• Provides telephone triage and crisis intervention to callers and, when necessary, assists with ensuring members have access to local services and resources.

Minimum Qualifications

• Master's degree in Social Work or Mental Health Counseling
• Minimum 3 years of Behavioral Health (Serious Mental Illness & Substance Use Disorder) experience in managed care utilization review, quality assurance, discharge planning. (Experience working in a Psychiatric Hospital Inpatient and/or Outpatient setting preferred)
• Experience in managing care for children/youth including high-risk groups, such as
• children with or at risk for SUD, children with SED, with co-occurring major mental disorders and SUD, who are involved in multiple services systems (education, justice, medical, welfare, and child welfare).
• Knowledge of New York State child serving systems is required. Experience working with community and family-based services is preferred.
• Previous experience within the Integrated Collaborative Care Model Approach preferred
• Knowledge and experience in children's physical health and BH services, Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services, and social service programs, including but not limited to Health Homes, OPWDD (Office for People with Developmental Disabilities), OCFS (Office of Child and Family Services) preferred.
• Experience with chronic condition management, particularly asthma, Diabetes, HIV, Heart Disease
• Knowledge of psychopharmacology, Psyckes, E-Paces, LOCADTR, InterQual, Locus/Calocus, HCS (UAS) MAPP preferred.
• Strong interpersonal and assessment skills, the ability to remain calm and poised with challenging providers.
• Medical Background & Bilingual preferred
• Previous experience with hospitals and other large volume providers to address HEDIS/QARR initiatives, preferred.

Licensure and/or Certification Required:

• Current valid unrestricted LCSW, LMSW, or LMHC NY State License

Professional Competencies:

• Integrity and trust
• Teamwork and problem-solving attitude
• Clinical skills and subject matter knowledge.
• Ability to learn and master UM/CM MetroPlusHealth systems and procedures, Microsoft Office, virtual meetings applications, and procedures.
• Excellent customer service
• Clear and concise oral and written communication skills
• Strong interpersonal and assessment skills, the ability to remain calm and poised with challenging providers.

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