Population Behavioral Health Specialist

POSITION SUMMARY:

The Population Behavioral Health Specialist will be responsible for innovation and implementation of patient outreach, patient care, care coordination, and process improvement initiatives to support patients in the Massachusetts Medicaid (MassHealth) Accountable Care Organization (ACO) and other value-based contracts. This position works within the Boston Medical Center Health System (BMCHS) Population Health Services (PHS) Behavioral Health team, collaborating closely with the Quality team, and will be responsible for participating in the design and leading the performance improvement initiatives for patients with co-morbid chronic medical, mental health, and substance use disorders. The BMCHS PHS team serves as the central hub for initiatives that drive performance in the MassHealth ACO program. In collaboration with ACO partners across Massachusetts, BMCHS aims to improve quality of care and outcomes for MassHealth members while managing utilization and total cost of care.

The role will involve direct patient outreach, clinical care, system navigation, and service coordination, and will tie to addressing several key ACO Quality metrics. Excellent patient engagement will be a critical skill for the individual in this role. This hybrid role will involve a 50% on-site presence at Boston Medical Center (BMC), as well as tele-health patient engagement. Key requirements for this role include excellent patient engagement, strong communication with other healthcare providers and practice leaders, and the ability to work independently and collaboratively. Clinical experience working with populations impacted by severe mental health and substance use disorders, including in acute episodes of illness, is required, as well as knowledge of relevant treatment systems. This role will also support the PHS Behavioral Health team in broader system-wide Behavioral Health strategy. This role is an ideal and unique opportunity for individuals seeking greater experience with system-level population health management. The candidate must be a behavioral health clinician in Massachusetts with a Master’s Degree or Doctoral Degree in clinical behavioral health field (e.g., MSW, Master’s of Mental Health Counseling, PsyD or PhD in clinical psychology).

Position: Population Behavioral Health Specialist

Department: Population Health

Schedule: Full Time

ESSENTIAL RESPONSIBILITIES / DUTIES:

Perform outreach, coordination, and care for complex patients with co-morbid chronic medical, mental health, and substance use disorders, following and in the setting of inpatient hospitalization and emergency department visits. This includes:  ​

• Outreach to patients and track response 

• Provide on-site and tele-health care

• Perform behavioral health assessment, including risk assessment 

• Conduct complete, accurate, and timely documentation in electronic health record 

• Perform coordination of care with other providers 

• As needed, connect patients to appropriate behavioral health care providers and medical providers 

• Participate with Population Health Directors in the design and process improvement of clinical innovation initiatives 

• Maintain up-to-date working knowledge of behavioral health resources and referral pathways 

• Participate in all training requirements and opportunities as designated by PHS Behavioral Health team 

• Participate with PHS Behavioral Health team, Quality team, and Analytics team on optimizing data pipelines for Behavioral Health quality 

• Maintain HIPAA standards and confidentiality of protected health information. 

• Adhere to departmental/organizational policies and procedures. 

• Complete other duties as specified by the Population Health Services Behavioral Health team 

• Must adhere to all of BMC’s RESPECT behavioral standards. 

(The above statements in this job description are intended to depict the general nature and level of work assigned to the employee(s) in this job.  The above is not intended to represent an exhaustive list of accountable duties and responsibilities required).

JOB REQUIREMENTS

EDUCATION:

• Master’s Degree or Doctoral Degree in clinical behavioral health field (e.g., MSW, Master’s of Mental Health Counseling, PsyD or PhD in clinical psychology)

CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED:

• Independent licensure preferred but not required (e.g., Massachusetts LICSW, LMHC, LMFT, or clinical psychologist)

EXPERIENCE:

• Experience with individuals with severe mental health and substance use disorders

• Experience working in systems that serve complex and vulnerable populations

KNOWLEDGE, SKILLS & ABILITIES (KSA):

• Strong understanding and familiarity with levels of care and how to navigate health and social services system

• Independence, creativity, and perseverance—this is a role involving a highly complex patient population and navigation across many parts of the health and social services system

• Sensitivity to ethnic, cultural, gender, and sexual orientation diversity, values, beliefs, and behaviors

• Experience with client centered practices including harm reduction approach and motivational interviewing

• Must display the use of appropriate independent judgment to determine appropriate course of action in resolving problems and in emergencies related to behavioral health needs of patients

• Ability to express self adequately in written and oral communication and to communicate effectively in an interdisciplinary, culturally diverse setting with clients, families, staff and agencies

• Excellent interpersonal skills and ability to work collaboratively

• Self-management skills, including ability to prioritize and organize

• Able to maintain professional boundaries

• Ability to work with diverse, safety-net population

• Skilled at working alongside difficult to engage patients—build rapport, trust

• Ability to work in a fast paced environment, inclusive of organizational skills, time management skills, critical thinking, and problem solving abilities

• Computer competency, inclusive of the ability to access and enter data through the electronic medical record system and manage personal email system

• Bilingual or multi-lingual skills (beyond that of English) appropriate to the patient population serviced, is preferred

Equal Opportunity Employer/Disabled/Veterans

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