Complex Care Coordinator

Boston Health Care for the Homeless Program•Boston, MA

4d•Hybrid

About The Position

Boston Healthcare for the Homeless Program (BHCHP) is seeking a Complex Care Coordinator to provide care coordination support for high-risk primary care patients. This role is integral to the Complex Care Management (CCM) services offered by BHCHP, extending support to medically complex, mostly homeless patients who may not be fully engaged with primary care or behavioral health services. The Complex Care Coordinator will work closely with multidisciplinary teams in BHCHP’s outpatient clinics and medical respite program to facilitate communication and collaboration for vulnerable patients. The position requires compassionate, dignified, and culturally appropriate interactions, incorporating social determinants of health to break down barriers faced by patients. The role involves flexibility to provide patient care coordination in assigned clinics within Boston (e.g., Jean Yawkey Place Clinic, shelter-based clinics) as well as through mobile outreach to other settings where patients frequent, reside, or receive care. The Complex Care Coordinator will manage a panel of 25 to 50 high-risk patients and may provide case management services to walk-in patients for up to 50% of their time, depending on site needs. The balance between panel management and walk-in case management will vary by site.

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: proficiency 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 in an assigned clinic or set of clinics with a multidisciplinary team of providers, nurses, behavioral health clinicians, and case managers.
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.
Outreach and engagement: 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.
Needs assessment: Complete intake and comprehensive needs assessment for primary care patients referred by Accountable Care Organizations or internal care teams for high-risk care management.
Support during transitions of care: 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 after hospitalization: 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 trainings on care management principles and practices.