Care Coordinator

BAMSI•Brockton, MA

42d•Hybrid

About The Position

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 applicant's home, but occasional travel outside 1 hour radius may occur.

Requirements

BA in social work, human services, nursing, psychology, sociology, or related field from an accredited college/university OR an Associate's degree and at least one year professional experience in the field OR at least three years of relevant professional experience.
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.
Commitment to MCCN values and mission.
Ability to travel on a regular basis; Must have valid driver's license and access to an automobile.
Ability to read and speak English. Fluency in other languages, including Spanish, Cape Verdean Creole, Haitian Creole preferred.
Strong computer knowledge, including 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.
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.

Nice To Haves

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.
Strongly prefer that a candidate will have a demonstrated understanding of and competence of Health Equity and in serving culturally diverse populations.
Strongly preferred experience in Microsoft Products and software i.e., Teams, Excel, Word, Outlook, etc.
Strongly prefer that a candidate will have a demonstrated understanding of and competence of Health Equity and in serving culturally diverse populations.

Responsibilities

Work collaboratively and effectively with care management, including Assigned or Engaged Enrollee, medical team and other providers to provide LTSS care management services.
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.
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 Enrollee's functional status, including Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) needs, since the completion of the Comprehensive Assessment.
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.
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.
Inform the Assigned or Engaged Enrollee about his or her options for specific LTSS services and programs and providers that may meet their needs.
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.
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.
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.
Participate in Enrollee's care team meetings to ensure effective communication among all disciplines â¨involved in individual's care.
Provide health and wellness coaching as directed by the Engaged Enrollee's care team and as indicated in the Enrollee's LTSS Person Centered Treatment Plan.
Maintain regular contact with Assigned or Engaged Enrollee to monitor and coordinate LTSS Person Centered Treatment Plan including quarterly face-to-face meetings.
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 Enrollee's inpatient discharge, discharge from twenty-four (24) hour diversionary setting, or transition to a community setting.
Support transitions of care by completing a follow up within seven (7) calendar days following an Enrollee's emergency department (ED) discharge. Coordinates clinical services and other supports for the Enrollee, as needed
Contacting the Enrollee's providers and collaterals to ensure accurate contact information when Assigned or Engaged Enrollees become unreachable.