Complex Care Coordinator (BMC Clinic)

Boston Health Care for the Homeless Program•Boston, MA

2d•$22 - $36•Hybrid

About The Position

Since 1985, the mission of Boston Health Care for the Homeless Program (BHCHP) has been to provide or assure access to the highest quality health care for all persons experiencing homelessness in the greater Boston area. By offering complex care management (CCM) services at BHCHP, our teams are able to extend supports to the outreach setting for a medically complex, mostly homeless group of patients who are not well engaged with primary care or behavioral health services. This role is designed to be better integrated with multi-disciplinary teams in BHCHP’s outpatient clinics to facilitate communication and collaboration on some of BHCHP’s most vulnerable patients. Complex care management requires compassionate, dignified, and culturally appropriate interactions with patients that have long been disenfranchised, incorporating social determinants of health, with the goal of breaking down the physical and systemic barriers that our patients face. This Complex Care Coordinator will provide care coordination support for a panel of up to 25 high-risk primary care patients at Boston Health Care for the Homeless Program. This involves flexibility to provide patient care coordination at BMC Clinic as well as through mobile outreach to other settings where the patient frequents, resides, or otherwise receives care. The Complex Care Coordinator will work with their supervisor to determine individualized outreach based on patient needs. Additionally, this individual will also work closely with an assigned primary care team at BMC Clinic, providing case management services to walk-in patients for about 50% of their time.

Requirements

A bachelor’s degree in a behavioral health field (e.g., social work, human services, psychology, sociology, or related field); or at least three years of relevant professional experience.
Able to work with multidisciplinary team maintaining a good rapport with nursing staff, medical staff, other departments, and visitors
Strong problem solving and communication skills (written and oral)
Excellent customer service skills and the ability to communicate professionally with employees and patients, both on the phone and in person
Efficient, organized, detail-oriented, and able to complete tasks in a time-sensitive manner
Self-directed with the ability to work independently in multiple settings
Flexible and adaptable to different health care delivery models
Computer skills: proficient with Microsoft Office, including Microsoft Excel, and entering narrative and other data into electronic medical records and other internet-based products
Willingness to travel to outreach/various sites
Valid driver’s license and car required or strongly recommended to travel to multiple sites

Nice To Haves

Knowledge of the network of services available to homeless persons, and experience working with homeless persons preferred
Prior case management experience preferred
Spanish or Haitian Creole language skills strongly preferred

Responsibilities

Work at BMC Clinic with a multidisciplinary team of providers, nurses, behavioral health clinicians, and case managers.
This position will include a combination of scheduled clinic sessions to see walk-in patients and outreach sessions as needed, with prior supervisor approval, to engage referred patients in the place where they frequent, receive care, and/or reside, and to accompany patients to appointments, court, etc.
Document patient encounters, as well as all outreach attempts, in the electronic health record.
Collaboratively develop, and document progress towards, patient-identified goals and a plan of care for each patient.
Coordinate services and assist patients with obtaining benefits, housing, housing tenancy supports, transportation, and other services that address their health-related social needs.
Support patients’ access to public health supplies by regularly stocking BHCHP’s public health vending machine and helping patients register for access to the machine.
Develop and maintain awareness of community resources and services available to patients.
Promote appointment adherence by assisting patients with scheduling and rescheduling missed medical and behavioral appointments, including specialty care, as needed. Support referrals to SUD treatment programs as needed.
Identify and develop cooperative working relationships with service providers for people experiencing homelessness, and coordinate housing supports using Homeless Management Information Systems (HMIS) when appropriate.
Work with patients to complete MassHealth applications and redeterminations to avoid disruptions to coverage.
Successfully complete the MassHealth Certified Application Counselor exam (CAC) within 60 days of hire and maintain active certification status.
Make best efforts, using multiple attempts and modalities, to successfully outreach and engage newly assigned patients within 30 days of their assignment to the care management panel, or within other timeframes as determined by payor.
Complete intake, comprehensive needs assessment, and care plans for primary care patients referred by Accountable Care Organizations or internal care teams for high-risk care management. Update these documents at least annually or when the patient’s condition changes as required by the ACOs.
Provide intensive, timely care coordination to patients during transitions of care, including but not limited to participating, as appropriate, in discharge planning with inpatient health care providers.
Follow up with patients face-to-face or by telephone following an inpatient or Emergency Department discharge to coordinate clinical and supportive services.
Follow billing, documentation, and assessment guidelines as required by payors.
Use data to evaluate outcomes and adjust interventions as needed.
Participate in weekly case conference meetings to discuss mutual patients with care team members to maintain integrated care model.
Participate in ongoing training on care management principles and practices.