Care Coordinator Case Manager - Dual Eligible Special Need Plan (D-SNP)

Mass General Brigham • Somerville, MA

1d • Hybrid

About The Position

The Care Coordinator will work as part of an interdisciplinary care team providing care management for DSNP members with medical, behavioral, and social needs, including Severe and Persistent Mental Illness (SPMI). The Care Coordinator serves as the Interdisciplinary Care Team Lead for members with low to moderate complexities and acts as a key partner in navigating Mass General Brigham Health Plan, MassHealth, and Medicare services. As an expert on the interdisciplinary team, the Care Coordinator conducts assessments, develops member-centered care plans, coordinates care, provides health education, and collaborates with providers to ensure comprehensive support. The Care Coordinator engages with Community-Based Organizations to support social engagement, recovery, Social Determinants of Health, wellness, and independent living. This position requires a hybrid work model, including practice-based, remote work, and in-person home and community visits to members when needed. The member population will include residents of Essex, Middlesex, Suffolk, Norfolk, Plymouth, Bristol, Dukes, and Nantucket counties.

Requirements

• Bachelor's Degree
• 1+ years of direct clinical experience (community case management)
• Valid Driver's License and reliable transportation
• Competency in working with multiple health care computer platforms (e.g. EPIC)

Nice To Haves

• Experience with Dual Eligible Populations (Medicare and Medicaid)
• Experience working with individuals with complex medical, behavioral, and social needs
• NCQA knowledge

Responsibilities

• Collaborate with interdisciplinary care teams—including primary care providers, specialists, LTSC, and GSSC—to support program enhancements, process improvements, and comprehensive care coordination.
• Participate actively in interdisciplinary care team meetings and establish consistent communication and reporting with providers and enrollees to review status, progress, and address challenging situations.
• Develop, update, and implement individualized, enrollee-centered care plans in partnership with enrollees and the care team, incorporating self-care, shared decision-making, and behavioral health considerations.
• Conduct outreach, assessments, and home visits via telephonic, electronic, or in-person methods to evaluate clinical status, identify needs, and provide ongoing community-based care management or referrals as appropriate.
• Monitor enrollees’ clinical status, identify early signs of deterioration, and intervene proactively to prevent unnecessary hospitalizations; act as clinical escalation point for urgent issues, providing triage and care coordination.
• Provide enrollee and family health education, coaching, and routine engagement tailored to individual needs, facilitating access to providers and supportive services.
• Utilize electronic medical record systems to accurately document, monitor, and evaluate interventions and care plans in compliance with DSNP regulations and organizational policies.
• Serve as a clinical resource and lead interdisciplinary care team member for assigned enrollees, supporting compliance initiatives, quality assurance, and collaboration with care management leadership.
• Perform additional duties as assigned by supervisors to support the overall goals of care management and enrollee well-being.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level