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Position: Care Coordinator Department: Long Term Supports and Services- BAP Program Schedule: Full Time POSITION SUMMARY: The role of the Long Term Services and Supports (LTSS) Care Coordinator is to provide LTSS care planning, care team participation, LTSS coordination, and support transitions of care, provide health and wellness coaching, and connect Boston Allied Partners members with social services and community resources. The LTSS Care Coordinator will follow defined timelines in order to meet the MassHealth requirements for billable activities. The Coordinator is responsible for documentation in the electronic health record platform and complying with all data entry, data integrity, and data tracking requirements. ESSENTIAL RESPONSIBILITIES / DUTIES: Essential Functions:
Contact and inform Assigned Enrollees of the option to receive LTSS Community Partner supports. The majority of Assigned Enrollees will be ages 3-21 for BMC Team Care Coordinators. Under the direction of the Assigned Enrollee, develop a LTSS Care Plan for Assigned Enrollees that agree to participate in the LTSS CP program. Ensure that the Enrollee receives necessary assistance and accommodations to prepare for, fully participate in, and to the extent preferred, direct the care planning process and that the Enrollee receives assistance in understanding LTSS terms and LTSS concepts. Collaborate with LTSS RN, under LTSS Clinical Care Manager supervision, to develop a person-centered care plan that encompasses numerous items such as MassHealth State Plan LTSS service(s) or program(s) recommended by the ACO, MCO, or DMH and desired by the Enrollee, other recommended LTSS desired by the Enrollee. Connect Enrollee to social services and community resources, identify and recommend Coordinate and collaborate with other case management entities and community resources. Participate in case conferences with the PCP, Nurse Care Managers, and representatives from other disciplines to identify the optimal plan of care for plan's members. Complete telephone calls to engaged Enrollees, annual, onsite reassessments, and transition planning and transition coordination within the expected LTSS CP timeframes. Provide health and wellness coaching; work with Engaged Enrollee to develop health and wellness goals. Attend and participate in agency and departmental meetings and trainings as required. Perform other duties as assigned.
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:
JOB REQUIREMENTS
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:
Preferred/Desirable:
Experience working with Medicaid recipients and community services Experience with Epic, eHana, or other EHR system
CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED:
Pre-employment background check Regular and reliable transportation and the ability to conduct face-to-face appointments with members, providers, community and state agencies
KNOWLEDGE AND SKILLS:
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 Second language is preferred 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 Bilingual (e.g., Spanish, Haitian Creole, Cape Verdean Creole) preferred 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
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Boston Medical Center
Dec 22, 2024