Care Coordinator

40hrs per week (Hybrid - Remote flexibility when not working in the field)

General Statement of Duties: The MCCN Care Coordinator will provide LTSS care coordination activities to youth and adult Enrollees of MCCN to facilitate the appropriate delivery of health care services and improve health outcomes. Such activities may include organizing care and facilitating communication across medical behavioral health LTSS social and pharmacy providers agencies and supports.

This position requires regular travel within the Southeast Region. Efforts will be made to contain travel within 1 hour of the Brockton office or the applicants home but occasional travel outside 1 hour radius may occur.

Responsibilities:

1. Work collaboratively and effectively with care management including Assigned or Engaged Enrollee medical team and other providers to provide LTSS care management services.
2. Work collaboratively with the care team to complete and utilize the Comprehensive Assessment results and work with Assigned or Engaged Enrollee to develop or update the LTSS Person Centered Treatment Plan within 122 days of assignment.
3. Ensure that the LTSS Person Centered Treatment Plan meets the requirements of EOHHS and notify the care team if changes have occurred to Assigned or Engaged Enrollees functional status including Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) needs since the completion of the Comprehensive Assessment.
4. Ensure the Assigned or Engaged Enrollee receives necessary assistance and accommodations to prepare for fully participate in and to the extent preferred direct the care planning process.
5. Ensure that the Assigned or Engaged Enrollee receives assistance in understanding LTSS terms and LTSS concepts including but not limited to information on their functional status; how family members social supports and other individuals of their choosing can be involved in the care planning process; self-directed care options and assistance available to self-direct care; and LTSS services or programs that are available to meet their needs and for which they are potentially eligible.
6. Inform the Assigned or Engaged Enrollee about his or her options for specific LTSS services and programs and providers that may meet their needs.
7. Assess the Assigned or Engaged Enrollee for social services and identify community and social services and resources that may support the health and wellbeing of the Assigned or Engaged Enrollee.
8. Conduct assessment for Flexible Services for all Assigned or Engaged Enrollees who are enrolled in an ACO. If Flexible Services are identified make recommendation to ACO for approval.
9. Coordinate all aspects of service delivery and promote integration with health care providers BH providers LTSS providers and community/social service provides that the Assigned or Engaged Enrollee may be receiving as outlined in the LTSS Person Centered Treatment Plan.
10. Participate in Enrollees care team meetings to ensure effective communication among all disciplines involved in individuals care.
11. Provide health and wellness coaching as directed by the Engaged Enrollees care team and as indicated in the Enrollees LTSS Person Centered Treatment Plan.
12. Maintain regular contact with Assigned or Engaged Enrollee to monitor and coordinate LTSS Person Centered Treatment Plan including quarterly face-to-face meetings.
13. Care Coordination activities include visiting locations in which the Enrollee is known to reside or visit; Conducting face-to-face home visits with the Enrollee on an initial and quarterly basis; complete in person follow up after discharge visit within 7 days following an Enrollees inpatient discharge discharge from twenty-four (24) hour diversionary setting or transition to a community setting.
14. Support transitions of care by completing a follow up within seven (7) calendar days following an Enrollees emergency department (ED) discharge. Coordinates clinical services and other supports for the Enrollee as needed
15. Contacting the Enrollees providers and collaterals to ensure accurate contact information when Assigned or Engaged Enrollees become unreachable.

Qualifications:

• BA in social work human services nursing psychology sociology or related field from an accredited college/university OR an Associates degree and at least one year professional experience in the field OR at least three years of relevant professional experience.
• Experience working with individuals with complex LTSS needs and credentialed as a community health worker health outreach worker peer specialist or recovery coach desired. Care Coordination and Behavioral Health experience preferred.
• Experience in navigating individual and family service systems and demonstrated the capacity to work collaboratively and effectively with families and community-based colleagues.
• Ability to use Electronic Health Records (EHR) Systems to document and coordinate services.
• Must be able to perform each essential duty satisfactorily.
• Strong interpersonal skills in terms of developing a working relationship with a variety of individuals in a variety of context. Ability to communicate effectively verbally and in writing.
• Strong organization skills with Attention to detail multi-tasking skills Prioritization skills Analytical skills Problem-solving skills and Team skills.
• Strongly prefer that a candidate will have a demonstrated understanding of and competence of Health Equity and in serving culturally diverse populations.
• Commitment to MCCN values and mission.
• Ability to travel on a regular basis; Must have valid drivers license and access to an automobile.
• Ability to read and speak English. Fluency in other languages including Spanish Cape Verdean Creole Haitian Creole preferred.
• Strongly preferred experience in Microsoft Products and software i.e. Teams Excel Word Outlook etc.

• Strong computer knowledgeincluding proficiency in contemporary Windows operating systems and Windows office suites with an emphasis on Word and Excel; ability to learn new systems; experience entering and working with data; and comfort and experience using mobile technologies.
• Knowledge regarding psychiatric rehab and understanding of recovery model.

• Strongly prefer that a candidate will have a demonstrated understanding of and competence of Health Equity and in serving culturally diverse populations.

• Must be able to perform each essential duty satisfactorily.
• Must hold a valid drivers license. Must have access to an operational and insured vehicle and be willing to use it to transport members.
• Must have ability to read English and communicate effectively in the primary language of the program to which he/she is assigned.

EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER

We at BAMSI appreciate your interest and consideration of roles in our  is an equal opportunity and Affirmative Action Employer encouraging diversity in the workplace.  All qualified applicants will receive consideration for employment without regard to their race color creed religion ancestry national origin sex sexual orientation gender identify age marital status family responsibilities pregnancy genetic information protected veteran or military status and regardless of whether the qualified applicants are individuals with  is the Lawhttp:// Accommodations for Applying/RecruitmentReasonable accommodations are adjustments made to remove workplace obstacles for qualified individuals with disabilities to apply for and perform their  who qualify under the Americans with Disabilities Act as amended may be eligible for a reasonable accommodation in BAMSIs application and selection process. A request for an accommodation will not affect opportunities for employment within BAMSI. Arrangements can be made if you have a disability that requires an accommodation for completing an application form interviewing or any part of the employment process. Requesting accommodations in writing or verbally can be initiated by a BAMSI employee qualified applicant or by someone acting on that persons behalf.  Either call  or send letter to Talent Acquisition 15 Christys Dr Brockton MA 02301. Note: please do not use these contacts to follow-up on job inquiries.