Harp Care Manager

The Health and Recovery Plan (HARP) Care Manager develops, facilitates, and communicates a plan of care in partnership with the member, his/her assigned Health Home, primary caregiver, the primary and attending physicians, and various Behavioral Health and/or Substance Use Disorder providers. In partnership with these parties, the HARP Care Manager assesses, plans, facilitates, and advocates for options and services to meet a HARP member’s complex health needs through communication and available resources. In addition, the HARP Care Manager is responsible for scheduling aftercare follow-up for members discharging from an acute behavioral health inpatient setting. This position ensures that members have a scheduled appointment in place, completes follow-up and reminder call to member and follows up with providers to ensure member’s compliance with aftercare. This position requires that all case management activities will be performed in field via community and facilities outreach. This position is 100% field based.

Work Shifts

9:00AM - 5:00PM

Duties & Responsibilities

• Clinically assess members for acute behavioral and physical health needs. Generating referrals to providers, community-based resources, and appropriate services and other resources to assist in goal achievement.
• Conduct Utilization Review for designated Case Management members for some diversionary levels of care. (CORE/HCBS, ACT).
• Expected to meet with members in their homes, shelters, other residential settings, at community agencies, hospital inpatient units and/or day hospital programs.
• Conduct initial and ongoing Behavioral Health clinical assessments.
• Develop a formal plan of care for all services needed for the HARP member. Notify physicians for any changes in member’s plan of care.
• Assists members and providers in accessing post-discharge aftercare related appointments. Works with inpatient facility team to identify appropriate follow-up care for CORE and HARP BH members.
• Responsible for outreaching members regarding adhering to 7-day follow up appointment to offer a 30-day appointment as part of HEDIS measures
• Responsible for mailing discharge aftercare letters with a list of referrals to members not reached by phone.
• Collaborate timely follow up with assigned nurses for clinical updates to plans of care.
• Document IDT care coordination notes between both internal MetroPlusHealth staff and external Health Home/CMA workers.
• Review and Approve submitted Health Home Plans of Care and ensure that CMA’s are conducting timely annual assessments. Review and approve CORE/HCBS requests;
  educating CMA workers about PROS and IOP options for members who opt out of receiving CORE/HCBS.
• Assist providers with achieving pay for performance goals and examine the feasibility of Value Based Payment with high volume providers for HARP line of business.
• 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 bi-Weekly Interdisciplinary Care Team (ICT) meetings which will feature newly enrolled, frequently admitted, high utilizing at risk HARP members.
• Attends and prepares for bi-Weekly Interdisciplinary Care Team (ICT) meetings which will feature newly enrolled, frequently admitted, high utilizing at risk HARP members.
• Oversee the coordination and delivery of comprehensive, quality healthcare and services for all members requiring care management in a cost-effective manner.
• Evaluate housing needs appropriately and assist with housing application process. Collaborating timely with MetroPlusHealth internal housing team for supportive assistance.
• Assist members with the coordination of services from various settings as appropriate. Including facilitating discharge from acute setting and alternate settings.
• Provides Care Coordination throughout the continuum of care.
• Optimizes both the quality of care and the quality of life for the MetroPlusHealth members. Identifies members appropriate for specialty programs.
• Documents in a comprehensive manner to ensure that all goals, interventions, and care coordination activities for each member in DCMS (EMR) syste