LTSS - Care Coordinator

Boston Medical Center • Boston, MA

50d

About The Position

Are you passionate about making a difference in people's lives? Join Boston Allied Partners as an LTSS Care Coordinator and play a key role in helping members live healthier, more supported lives. In this role, you'll: Develop and implement personalized care plans that empower members and their families by leveraging available long-term services and supports (LTSS). Actively participate in care teams, ensuring smooth coordination across providers. Support members through transitions of care, connecting them to the right services at the right time. Provide health and wellness coaching to help members reach their goals. Link members with community resources and social services to address barriers beyond healthcare. You'll work within established timelines to meet MassHealth requirements, ensuring services are not only compassionate but also compliant. Accurate documentation is key-you'll maintain records in our electronic health record system, upholding data integrity, tracking requirements, and supporting program success. If you're organized, compassionate, and thrive on helping others navigate the healthcare system, we'd love to meet you. In this role, you'll play a vital part in supporting children, youth, and families by ensuring they have access to the care, services, and resources they need.

Requirements

• LICSW or LCSW
• Bachelor's degree in social work, human services, nursing, psychology, sociology, or related field
• Associate's degree and at least one year of professional experience in the field
• at least three years of relevant professional experience.
• Pediatric and/or Behavioral Health experience strongly preferred
• Pre-employment background check
• Regular and reliable transportation and the ability to conduct face-to-face appointments with members, providers, community and state agencies
• Ability to visit consumers in the environment in which they reside such as the individual's home, apartment, shelter, group home, etc.
• Must possess advanced skills in consumer assessment and be able to assess the physical conditions of the consumer's home as well as the consumer.
• Exhibit interpersonal flexibility, initiative, and teamwork.
• Solid organizational skills
• Ability to use computer systems in various environments (mobile phone, desktop, tablet).
• Ability to learn and utilize various software programs.
• Acceptance of the right to self-determination.
• Maintains consumers' rights, privacy and confidentiality in all aspects of the job, including those relating to diagnosis and consumer records.
• Promotes and employs ethical actions at all times with consumer's families and others.
• Participates in performance improvement activities as requested to do so.
• Identifies and communicates opportunities for improvement.
• Demonstrates excellent customer service by conducting daily activities, communications and interactions in a cooperative, positive and professional manner.
• Proficient in reading, writing, and communicating in English
• Communicate in a manner appropriate and respectful to the comprehension level of the consumer and/or family.
• Maintains the responsibility for punctuality and attendance as defined in the agency policy to ensure optimal operation of the program.
• Submits requests for vacation, days off, etc. in accordance with department policy.
• Regular and reliable attendance is an essential function of the position.

Nice To Haves

• Experience working with Medicaid recipients and community services
• Experience with Epic, eHana, or other EHR system
• Second language is preferred
• Bilingual (e.g., Spanish, Haitian Creole, Cape Verdean Creole) preferred

Responsibilities

• Engage members and families - Reach out to individuals referred into the program (primarily ages 3-21) to inform them about the option to receive LTSS Community Partner supports.
• Create meaningful care plans - Partner with enrollees and their families to develop personalized LTSS care plans that reflect their preferences, goals, and needs.
• Empower participation - Provide guidance and accommodations so members can fully understand LTSS services and actively participate-or even lead-their care planning process.
• Collaborate across teams - Work with LTSS RNs, clinical care managers, PCPs, and other care team members to deliver a person-centered, comprehensive plan of care.
• Connect to resources - Link members to social services, community resources, and state programs that address both medical and non-medical needs.
• Support wellness - Provide health and wellness coaching, helping members set and achieve personal health goals.
• Coordinate transitions - Assist members with smooth care transitions through timely assessments, transition planning, and follow-up support.
• Stay connected - Maintain regular contact with members through phone calls, reassessments, and case conferences.
• Grow with us - Participate in training sessions, team meetings, and professional development opportunities.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Industry: Hospitals
• Number of Employees: 1,001-5,000 employees