Behavioral Health Care Manager
Company: Cityblock Health
Location: Bowling Green
Posted on: June 3, 2021
Cityblock Health is the first tech-driven provider for
communities with complex needs-bringing better care to where it's
needed most, block by block. Founded in 2017 on the premise that
"health is local" and based in Brooklyn, we are backed by
Alphabet's Sidewalk Labs along with some of the top healthcare
investors in the country.
Our mission is to improve the health of underserved communities.
Importantly, our solutions are designed specifically for Medicaid
and lower-income Medicare beneficiaries, and we meet our members
where they are, bringing care into the home and neighborhoods
through our community-based care teams and Virtual Care
In close collaboration with community-based organizations, local
providers, and leading health plans, we are reorganizing the health
system to focus on what matters to our members. Equipped with
world-class, custom care delivery technology, we deliver
personalized primary care, behavioral health, and social services
to deliver a radically better experience of care for every member
and community we serve.
Over the next year, we'll grow quickly to bring better care to
many more members and their communities. To do this, we need people
who, like us, believe that everyone should have good care
for what matters to them, in their community.
Our work is grounded in a belief in the power of a diverse
community. To close gaps in care and advance equity in the
communities we serve, we have to start with making our own team
diverse and inclusive. Our ways of working are characterized by
creativity, collaboration, and mutual learning that comes from
bringing together a community from diverse backgrounds and
perspectives. We strive to ensure that every person on the
Cityblock team, and every Cityblock member, feels supported and
included as a part of our community.
- Aim for Understanding
- Be All In
- Bring Your Whole Self
- Lean Into Discomfort
- Put Members First
About our Team:
We employ a field-based, home-based care model and are committed
to meeting members where they are--in their homes, in their
community, and in our Hubs. You will go above and beyond to connect
with Cityblock members in a non-judgmental, respectful and empathic
manner, to meet their needs, and to provide feedback to the system
as a whole as we strive to do better every day.
About the Role:
The Cityblock Community Behavioral Health Care Manager delivers
integrated primary and acute medical care, behavioral health and
social care, powered by relationships and designed to advance
equity in access and outcome. By delivering these acute and
longitudinal services in-home through a combination of digital and
in-person connections, we proactively work with members to increase
time spent in the community rather than facilities.
The Community Behavioral Health Care Manager (BHCM) provides
proactive care management and care coordination to individuals with
primary behavioral health conditions in the home, community and
tele-health. The BHCM works as a part of an integrated care team
including the member, their supports, the Cityblock care team
(providers, CHPs, RNs and BHS (who provide direct therapy to
members)), the PCP, specialists and other community care managers /
supports. The BHCM identifies risk factors, reviews the assessment,
identifies the member's stages of change, develops and engages
members in action plans and behavior changes and ensures members
trust us to call us first with any new changes or symptoms. BHCMs
are accountable for ensuring members utilize resources effectively
and efficiently, ensuring members have achieved designated health
outcomes. In addition, many of these members have medical and
social needs that the BHCM will coordinate and advocate for with
the care team.
You will work in a radically different model of healthcare.
- Expect collaboration, shared-decision making, and partnership
across clinical and non-clinical care team members, including our
team of Community Health Partners.
- Be the accountable care manager for the members on your panel
with significant behavioral health diagnoses.
- Co-manage a population living with complex medical, social and
behavioral health conditions
- Work a full-time 40 hour week, Monday-Friday 9am to 5pm ET.
Your work may take you outside of normal business hours as urgent
member needs arise.
- Refer to Cityblock Behavioral Health Specialists (BHS) and make
referrals to community therapists and psychiatrists as needed.
Cityblock BHS' provide individual and group therapy, consultations
and acute care as well as bridge therapy until a long term plan is
created for members that need continued support.
- Follow up with members closely to ensure they follow through
with care recommendations, eliminating barriers to engagement with
their internal and external providers.
- Coordinate existing services in the community or ensure
Cityblock BHS' provide bridge therapy to longer-term behavioral
- Be an expert in measuring stages of change. Understand member
readiness to make changes, appreciating barriers to change.
Anticipate relapse and intervene accordingly.
- Follow members closely while they are inpatient, in residential
programs and/or intensive day programs. Liaise with both the
inpatient team and Cityblock team to ensure continuity of
- For transitions of care, ensure follow up and escalation plans
are detailed, clear and achievable. Closely follow members through
the transition period according to CBH transition of care
- Actively participate in daily team huddles and case conferences
to advise, develop and document behavioral health and care
management needs and goals as part of member's Member Action Plan
- Actively participate in planning and/or implementation of
initiatives related to Behavioral Health integration and
collaboration with external vendors, community-based service
providers, and/or the larger Cityblock Care Team
- Utilize our custom-built care facilitation platform, Commons,
and the EMR to document notes, track tasks and communicate with
other members of the care team.
Requirements for the Role:
- You are an LICSW, LCSW or LMHC in the state of
- 5 years minimal experience in assessing, planning, and managing
patient care as acquired through three years of clinical experience
in an acute care hospital; rehabilitation or home care
- Working knowledge of Medicare and Medicaid programs and
experience with regulatory compliance and reporting
- 3-5 years in care management role preferably in a health plan,
ambulatory care, community service providers managing high risk
population, duals preferred and transitions of care
- Advanced communication and interpersonal skills with all levels
of internal and external customers.
- Are Tech savvy, able to talk, type, and document in the moment.
Comfortable using Google Suite, Slack, and other tech
- Are excited about how technology can support your work and help
drive the ongoing evaluation toward new and better care
- Strong organizational and communication skills
- Extensive knowledge of Medicare and Medicaid, benefits and
- Proven experience in developing and sustaining internal and
external client relationships with healthcare professionals,
including community service providers
- Strongly prefer
- Bilingual language skills, most prevalent need includes
Spanish, Vietnamese, French Creole, Cantonese, Russian,
- Experience with Medicaid and / or members with social
How We Define Success:
- Performs a variety of diverse and complex care management
responsibilities, ensuring that all service needs are met through
development and monitoring of an integrated action plan
- Responsible for managing a panel of members with a primary
behavioral health diagnosis
- Utilizes relevant behavioral health interventions to educate
members, manage their care and support the development of
self-management and self efficacy skills for members
- Ensures assessments are completed, initially and ongoing,
reviews them and ensures that key insights are integrated into a
comprehensive care plan in coordination with the interdisciplinary
- Maintains an integrated care plan for identified needs and
monitors the delivery of services for individuals with co-morbidity
to improve both behavioral health and physical health outcomes and
identifies the need to update goals and interventions based on
- Utilizes techniques such as motivational interviewing, harm
reduction, trauma informed care principles, de-escalation
techniques and other evidence-based practices to deliver
- Identifies service delivery gaps and barriers, ensures
appropriate evaluations, service planning and delivery and monitors
- Partners with the provider and clinical team on the process of
- Conducts disease coaching, provides education to members and is
proficient in the management of multiple common comorbidities
- Works closely with other members of the care team, members'
family and caregivers, and case management staff, particularly the
Department of Mental Health, in care planning
- Responsible for coordinating with the Long Term Services
Support Coordinator (LTS-C) in the co management BH-designated
members with LTSS needs
- Collaborates with care team in coordination of care and care
planning during transitions of care Identifies service delivery
gaps and barriers, ensures appropriate evaluations, service
planning and delivery and monitors member progress
Nice to Have, But Not Required:
- Interest or experience in healthcare assessments and
- Interest or experience in analysis of healthcare data
What We'd Like From You:
- A resume and/or LinkedIn profile
- A short cover letter, please!
Cityblock values diversity as a core tenet of the work we do and
the populations we serve. We are an equal opportunity employer,
indiscriminate of race, religion, ethnicity, national origin,
citizenship, gender, gender identity, sexual orientation, age,
veteran status, disability, genetic information, or any other
We do not accept unsolicited resumes from outside
recruiters/placement agencies. Cityblock will not pay fees
associated with resumes presented through unsolicited
Keywords: Cityblock Health, Bowling Green , Behavioral Health Care Manager, Other , Bowling Green, Kentucky
Didn't find what you're looking for? Search again!