Care Coordinator – New Bedford

****This position includes a $1,000 sign on bonus. *****

Due to Agency growth, we have a full time (40 hours per week) Care Coordinator position in our Long Term Services and Supports (LTSS) Community Partner (CP) program in New Bedford and surrounding area. This position may be partially remote with drop in office in New Bedford and occasional travel to Fall River. The hours are Monday through Friday, 8:00 a.m. - 5:00 p.m.

Job Summary:

The Long-Term Services and Supports (LTSS) Community Partners (CP) Care Coordinator is responsible for providing Care Coordination activities and the delivery and receipt of services to Enrollees assigned by Accountable Care Organizations (ACO), Managed Care Organizations (MCO), or MassHealth.

Duties and Responsibilities:

• Execute all required documents for participation in the CP program including, but not limited to, a Participation Agreement Form and all required authorizations for Use and Disclosure as necessary for providing CP Supports.
• Conduct a face to face Comprehensive Assessment for each Enrollee, which informs the development of the Care Plan. Share results of the Comprehensive Assessment with Enrollee, Care Team, PCP, ACO/MCO, and other providers that serve the Enrollee, and document in EHR. Update the Comprehensive Assessment on annual basis if needed.
• As part of the Community Partners Team (CPT), utilizing the Comprehensive Assessment and under the direction of the Enrollee/Authorized Representative, complete the Care Plan, identifying any current providers, enrollee’s chosen Care Team and support system, preferences, goals, strengths, needs and cultural considerations.
• Utilize appropriate interventions to engage and support the Enrollee in development of the Care Plan including self-directed care options and informed choice for applicable services, programs and providers. Help facilitate participation of enrollee’s PCP or designee in care planning process.
• Complete updates to the Care Plan upon request of the Enrollee, as needed due to major changes in functional, ADL or IADL status, and at least quarterly, including development of Annual Care Plan at appropriate time if Enrollee has identified new goals.
• Ensure Care Plan is approved by the Enrollee and shared with the Primary Care Provider, ACO / MCO, Care Team, and other service providers within required program time frames.
• Utilize alternative methods and formats of documentation and communication to ensure the Enrollee understands the Care Plan; including but not limited to, accommodation for sensory disabilities, literacy, and primary language of the Enrollee.
• Act as facilitator for communication across all members of Care Team to assure status updates and ongoing monitoring of the implementation of the Care Plan, which may include changes in status for health, housing, natural supports, and caregivers, and avoidance of duplication of services.
• Provide Health and Wellness coaching, including symptom management, education on health risk factors and behaviors, health promotion, management of chronic diseases, and setting and achieving health and wellness goals.
• Maintain contact with enrollee on a monthly basis, with face to face visits being offered monthly and occurring on a quarterly basis at minimum.
• Help facilitate Enrollee’s access to needed services, including but not limited to, Flexible Services, ACO/MCO chronic disease management programs, LTSS and other Community Resources.
• Advocate for and assist with navigating any Health Inequities discovered.
• Provide support for transitions of care and facilitate the development of appropriate discharge plans as indicated, in conjunction with the Registered Nurse.
• Conduct follow-up within 7 business days following any transition in care including Emergency Department visits and conduct a face-to-face visit with enrollees within 7 business days after acute or post-acute hospital discharge, in conjunction with the CP Team.
• Maintain compliance with performance metrics, including MassHealth Quality Measures.
• Complete all documentation required for the delivery of LTSS Community Partners program services in a timely manner.
• Foster and maintain collaborative relationships with Primary Care Providers, specialists, ACO / MCO Care Managers, Social Service Organizations and representatives from state agencies.
• Work in a professional and confidential capacity related to all program services and communications.
• Attend regular supervisory meetings both on a team and individual basis, as required.
• Participate in person-centered planning training, Motivational Interviewing and other required trainings and activities on an on-going basis.
• Maintain cultural competency awareness and sensitivity to cultural, religious, ethnic, disability, and gender/sexual orientation preferences.
• Respond to reasonable expectations of the Agency and/or supervisor.

Education and Experience:

• Must have a minimum of High School Degree (or equivalent) and at least three years of experience.
• or an Associate’s Degree and at least one year of experience in the field.
• or a Bachelor’s Degree in social work, human services, nursing, psychology, sociology, or a related field.
• Must have strong written and oral communication skills and demonstrated computer skills.

This is a benefits eligible position. Benefits include medical, dental, vision insurance, long term disability, life insurance, 403(b), flexible spending account, three weeks vacation, twelve paid holidays and generous earned sick time.

Family Service Association is an Equal Opportunity Employer. Make a difference and join our team today!

Family Service Association is a comprehensive private, non-profit social service agency dedicated to the development and implementation of services designed to provide strength and support to individuals and families throughout southeastern Massachusetts. Headquartered in Fall River, Family Service Association strives to increase the capacity of individuals and families to cope with the stresses of family life and interpersonal relationships in a positive, productive and health-improving manner. This agency is a leading provider of professional social services in the South Coast region of Massachusetts, with a 130 year tradition of high quality.

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