Care Coordinator - Street Team

Boston Health Care for the Homeless Program • Boston, MA

1d • Onsite

About The Position

Since 1985, BHCHP’s mission has been to ensure unconditionally equitable and dignified access to the highest quality health care for all individuals and families experiencing homelessness in greater Boston. Over 10,000 homeless individuals are cared for by Boston Health Care for the Homeless Program each year. They are committed to ensuring that every one of these individuals has access to comprehensive health care, from preventative dental care to cancer treatment. Clinicians, case managers, and behavioral health professionals work in more than 30 locations to serve some of the community’s most vulnerable—and most resilient—citizens. The program is committed to building bridges and breaking down barriers, including systemic racism, and provides community-based health care services that are compassionate, dignified, and culturally appropriate, incorporating social determinants of health. The central focus of their mission is the care of individuals who avoid shelters and sleep on the streets, a population suffering high mortality rates and complex co-occurring medical, mental health, and addiction problems. Boston Health Care for the Homeless Program Street Team is seeking a full-time Care Coordinator to join its multidisciplinary team. This role involves working with an integrated and multidisciplinary primary care team that seeks out unsheltered individuals, offering urgent and ongoing medical and behavioral health care. The ideal candidate is flexible, compassionate, and self-motivated with a strong commitment to serving vulnerable populations. This role requires delivering low-threshold, high-quality care coordination in nontraditional settings such as streets, encampments, and community locations. The Care Coordinator will be responsible for providing case management and care coordination for a panel of adults with a history of chronic unsheltered homelessness, including high-risk patients in the Behavioral Health Community Partners Program. This includes completing required assessments and documentation based on insurance and program requirements, while working closely with the Street Team to address barriers to health care with a strong focus on social determinants of health.

Requirements

• Experience working with vulnerable populations, including people with a history of trauma, those experiencing socioeconomic stress, homelessness, mental health challenges, or substance use disorders
• Strong interpersonal skills and case management problem-solving
• Efficient, organized, detail-oriented, and able to complete tasks in a time-sensitive manner
• Self-directed with the ability to work both independently and collaboratively with clinical staff on shared patient goals
• Demonstrated commitment to working with underserved and vulnerable populations
• Ability to work collaboratively as part of a multidisciplinary healthcare team using a coordinated, patient-centered approach
• Ability to manage a fast-paced workload, prioritize tasks, and maintain professionalism in stressful or unpredictable situations
• Self-motivated with the ability to work both independently and collaboratively with team members across multiple locations
• Ability to travel regularly between outreach locations and access community sites
• Ability to use standard office and field technology, including computers, tablets, and telephones, for documentation and communication
• Ability to lift and carry 5–10 pounds regularly and up to 15–20 pounds occasionally
• Ability to climb stairs, bend, stoop, and navigate uneven terrain commonly encountered during community and street outreach
• Ability to walk 5+ miles/day in all weather conditions—you will do street outreach outside in all seasons

Nice To Haves

• Bachelor’s degree preferred but not required

Responsibilities

• Provide outreach-based care coordination and non-judgmental support in collaboration with other Street Team members
• Engage individuals experiencing substance use disorders and mental health conditions using low threshold principals and trauma-informed care practices.
• Conduct health and needs assessments and collaborate with patients and the primary care team to develop and implement integrated care plans
• Assess social determinants of health (e.g., housing, food access, benefits, transportation) and support patients in addressing these needs based on their goals and priorities
• Coordinate as needed with outreach and housing partners to address social determinants of health for shared patients.
• Track patient appointments, referrals, and primary care; follow up with patients to support appointment adherence or rescheduling when appointments are missed
• Conduct street outreach and home visits with Street Team as necessary
• Represent the Street Team at housing-related meetings with the City of Boston and other partner agencies regarding unsheltered patients empaneled to the Street Team
• Coordinate and facilitate monthly meetings with housing partners regarding patients currently housed and empaneled to the Street Team

Benefits

• The compensation increases based on years of experience and ranges from $22.25 - $35.60 hourly
• BHCHP full time employees are eligible for our competitive time off program, health, dental and vision insurance, 403B retirement savings plan, pre-tax MBTA pass program with 40% discount, additional compensation for demonstrated bilingual proficiency and more.
• Benefits are prorated for part-time employees

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: No Education Listed
• Number of Employees: 101-250 employees