Complex Care Management Team Lead

Boston Health Care for the Homeless Program•Boston, MA

3d•$24 - $38•Onsite

About The Position

Boston Health Care for the Homeless Program (BHCHP) has been dedicated since 1985 to providing unconditionally equitable and dignified access to high-quality healthcare for individuals and families experiencing homelessness in greater Boston. BHCHP serves over 10,000 homeless individuals annually, offering comprehensive care from preventative services to advanced treatments. Our multidisciplinary teams operate across more than 30 locations, serving vulnerable populations with compassion and respect. BHCHP is committed to transforming healthcare by recognizing shared humanity, centering dignity, and breaking down systemic barriers, including racism. We provide community-based, compassionate, dignified, and culturally appropriate care, addressing social determinants of health to overcome barriers to primary and behavioral health services.

Requirements

At least three years of relevant professional experience, including experience with leading team operations in a health care setting
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.
Experience with data analysis and reporting to support a variety of end users and organizational requirements combining clinical, financial, and operational data
Ability to critically evaluate and assure data quality in reports and data sets
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)
Self-directed with the ability to work independently in multiple settings and consistently meet deadlines
Prior case management experience required
Computer skills: proficient with Microsoft Word and Excel, as well as electronic health records

Nice To Haves

Knowledge of the network of services available to homeless persons, and experience working with homeless persons preferred
Spanish or Haitian Creole language skills strongly preferred
Valid driver’s license and car required or strongly recommended to travel to multiple outreach sites

Responsibilities

Work in an assigned clinic at Jean Yawkey Place with a multidisciplinary team of providers, nurses, behavioral health clinicians, and case managers.
Conduct outreach sessions as needed, with prior supervisor approval, to engage referred patients in the place where they frequent, receive care, and/or reside. 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 payor-determined timeframe.
Document patient encounters, as well as all outreach attempts, in the electronic health record. Follow billing, documentation, and assessment guidelines as required by payors.
Complete intake and comprehensive needs assessment for assigned patients.
Collaboratively develop and document progress towards patient-identified goals and plan of care.
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 medical and behavioral appointments as needed. Support referrals to SUD treatment programs as needed.
Provide coordination to patients during transitions of care; participate, 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.
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.
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.
Manage CCM-related data reporting and monitor program metrics for the team. Develop plans with CCM Program Manager to help incentivize and manage performance for the team.
Work with Accountable Care Organizations to facilitate timely and secure data exchange and transfer related to CCM contract requirements.
Assist CCM Program Manager with monitoring and managing timely and accurate tracking and documentation of enrollments, assignments, and dis-enrollments as needed.
Assist the CCM Program Manager to onboard, orient, train, and support new care coordinators. Provide mentorship and feedback to support care coordinator performance.
Support the CCM Program Manager in implementing policies, workflows, and operational supports that enable BHCHP to meet CCM-related quality benchmarks.
Manage routine operations of the CCM Team when the CCM Program Manager is not present.