Licensed Care Manager, Complex Discharge Planning

Community Care Cooperative•Boston, MA

7h•Hybrid

About The Position

As an integral member of the care management team, the Licensed Care Manager (CM) will have the opportunity to have a profound impact on the lives of people living with complex and/or chronic conditions, many of whom also face multiple barriers in their lives, which make it difficult for them to achieve the self-care required to improve their health and well-being. This position is currently hybrid, but requires flexibility, and may vary from day-to-day to meet members where they are. Outreach methods are based on the needs of the organization and the member, and may include telephonic, or in-person engagements in a variety of potential settings, such as the health center/practice, community, home, or an inpatient facility.

Requirements

Licensed Clinical Social Worker (LCSW or LICSW), or Licensed Mental Health Counselor (LMHC) or LSW with 3-5 years of Care Management/ Complex Discharge Planning Experience
2-5 years of inpatient or community Social Work experience providing patient-centered outreach, behavioral health services, needs assessment, and support
A valid driver's license and provision of a working vehicle
In compliance with Infection Control practices per Mass.gov recommendations, we require all employees to be vaccinated consistent with applicable law.

Nice To Haves

Demonstrated success in working as part of a multi-disciplinary team including communicating and working with Providers, Pharmacists, Nurses, Community Health Workers, and other health care teams
Demonstrated success in identifying and supporting members with high utilization patterns, complex needs, and social risk factors to reduce avoidable admissions/readmissions and improve continuity of care
Must demonstrate excellent interpersonal communication skills
Ability to flexibly utilize clinical expertise to solve complex problems
Experience working with patients with chronic medical and behavioral health needs
Must be flexible and adaptable to change
Demonstrate the ability to work independently
Bi/multi-lingual preferred
Experience using appropriate technology, such as computers, for work-based communication
Experience and proficiency with Microsoft Office and online record keeping
Experience with anti-racism activities, and/or lived experience with racism is highly preferred
Experience within the ACO’s member population preferred, including Medicare/Medicaid member populations
Experience working with Federally Qualified Health Centers/ Primary Care Provider practices is strongly preferred

Responsibilities

Conducts Comprehensive Clinical Assessments for both adult and pediatric members
Ensure that medication reconciliation is completed, as indicated. BH Care Managers will refer all medication reconciliations to a Clinical Pharmacist
Actively engages members and caregivers in collaborative care planning, focusing on medical, behavioral, social, and member-centered needs. Coaches and guides member/representative to meet bio/psycho/social goals
Manages complex discharge planning needs for members (adult and pediatric) experiencing extended inpatient stays or frequent ED visits, and actively participates in regular meetings with hospital staff, providers, care team, and community services
Partners with MassHealth and other state agency contacts to facilitate care transitions to the safest level of care
May be required to meet members while they are inpatient to provide education and support about the discharge process and transition members into care management
Assesses the member’s knowledge of their medical, behavioral health and/or social conditions and provides education and self-management support plans based on the member’s needs and preferences
Connects members with primary care, behavioral health, social services, Community Partner, respite, and other community-based services, as indicated and appropriate
Participates in the integrated care team meetings and clinical rounds, as required
Maintain accurate, timely documentation in electronic systems, including health center/practice EHRs
Provides coverage for team members who are out of office
Other duties as assigned