POSITION SUMMARY:

The Behavioral Health (BH) Community Partners (CP) Program is a set of community-based organizations serving MassHealth members enrolled in either an Accountable Care Organization (ACO) or Managed Care Organization (MCO). The CP Program partners with health care providers, social services organizations and community resources to support members with complex behavioral health needs. This role will be based in the community and serve as a vital link connecting homeless individuals with serious mental illness, substance use disorders, and/or complex medical illnesses with needed care including mental health, substance use, and primary care as well as services that address social determinants of health needs.

The BH CP Care Coordinator will work as part of an interdisciplinary BH CP team and take responsibility for coordinating the care for up to 50 enrollees. The BH CP Care Coordinator will work closely with other care team members and will be responsible for engaging their enrollees regularly (several times a month), mostly face to face, and making sure that the enrollee is getting connected to vital services and progressing towards the goals outlined in their Person-Centered Care Plan.

Position: Care Coordinator, Behavioral Health

Department: Pop Health Care Management

Schedule: Full Time

Essential Functions:

• Under the direction of the assigned Enrollee, develop a BH Care Plan with nurse case managers.

• Work with the nurse care managers, conduct timely Comprehensive Assessments

• Communicate and engages with enrollees regularly and helps enrollee progress on goals identified in Patient Centered Care Plan.

• Document into data platform regarding enrollee progress on Care Plan goals, all enrollee encounters, care coordination notes. All patients on panel require at least once/month contact and documentation.

• Assist nurse care managers and BH CP teams with arranging enrollee appointments for services needed and other related assessments; accompanies enrollees to appointments as needed

• Triage and troubleshoot care need issues for enrollees; works with nurse care managers to address needs

• Participate in team case conferences and advocate for enrollees' needs

• Participate in BH CP training and learning initiatives.

• Remind enrollees about keeping appointments, filling prescriptions, etc.

• Work with BH CP team on dev & implementation of Patient Centered Care Plan

• Request & send medical records to for care coordination purposes to providers, ACO, MCO as needed

• Be flexible and able to multi-task.

Other Duties

• Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Supervision Received:

• Weekly and ongoing from Clinical Care Manager and Registered Nurses

JOB REQUIREMENTS:

• Bilingual English and Spanish required for this position.

Education:

• (A.) LICSW or LCSW; or (B.) Bachelor's degree in social work, human services, nursing, psychology, sociology, or related field; or (C.) Associate's degree and at least one year of professional experience in the field; or (D.) at least three years of relevant professional experience.

Experience:

• Experience working with homeless populations and/or populations with mental illness and substance use disorders.

Preferred/Desirable:

• Experience with Epic, eHana, or other EHR system

Certification or Conditions of Employment:

• Pre-employment background check

• Regular and reliable transportation and the ability to conduct face-to-face appointments with members, providers, community and state agencies

Competencies, Skills, and Attributes:

• 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.

Effort:

• Regular and reliable attendance is an essential function of the position.

• Work may be performed in a typical interior/office work environment or in a home office except when conducting face-to-face visits.

• Face-to-face visits may be conducted in a member's home, shelters, physician practices, hospitals, or at a mutually agreed upon location between the member and the care manager and with community and state agencies, as appropriate.

• No or very limited physical effort required. No or very limited exposure to physical risk.

Equal Opportunity Employer/Disabled/Veterans