Outreach Care Coordinator

1 month ago

Fall River, United States Family Service Association - Fall River Full time
Job DescriptionJob Description

***$1, 000 SIGN ON BONUS***

We have a full time (40 hours per week) The hours are Monday through Friday, 8:00 a.m. - 5:00 p.m.  This is an Outreach Care Coordinator position in our Long Term Services and Supports (LTSS) Community Partners (CP) program.   Position may be based at one site but will service Fall River, New Bedford, Mashpee and Brockton.

The Long Term Services and Supports (LTSS) Community Partners (CP) Outreach Care Coordinator is responsible for making initial contact with hard to reach members and promoting coordination in the delivery and receipt of services to enrollees assigned by Accountable Care Organizations (ACO) and Managed Care Organizations (MCO), or Mass Health.

Duties and Responsibilities:

  • Respect the confidential nature of all program services and communications therewith.
  • Conduct outreach to assigned enrollees to inform about the functions of a CP Program, role of the Care Coordinator, the optional nature of CP enrollment, choice in CP providers, the benefits of enrollment and the process for enrolling. Provide written documentation to members as warranted.
  • Document all outreach attempts which typically include a minimum of 3 phone call attempts; and additional strategies including face-to-face attempts if warranted, and other correspondence.
  • Make contact with members during outreach to complete Follow Up after Discharge summary as needed.
  • Schedule Intake appointments for Care Coordinators as appropriate.
  • Complete Risk Assessment as required.
  • Inform potential member of Participation Agreement and facilitate sending it to the enrollee.
  • Facilitate warm hand-off for completion of Comprehensive Assessment with ACO / MCO partners.
  • Responsible for marketing program to ACO / MCO Health Centers, hospitals, PCP offices and other entities including maintaining collaborative relationships with same.
  • Responsible to delegate assignments to part-time Outreach Worker as applicable
  • Determination of caseload assignments per geographic area on a monthly basis.
  • Complete No Contact, Disengagement, request for information, Intake Packet and other letters as required to send to members during absence of Intake Specialist.
  • Completion of disenrollment forms for members on assigned caseload. 
  • Assignment as Care Coordinator to assist in gaps in coverage as needed, or in growing area of need in a geographical region, including but not limited to the following duties and responsibilities.
  • Obtain the Comprehensive Assessment from the referring ACO/MCO, integrate findings into person-centered Care Plan and provide update as needed for any changes in functional status, ADL, or IADL needs.
  • Ensure LTSS Care Plan is approved by the Enrollee and the Primary Care Provider within required time frames. Ensure Care Plan is shared with all members of the care team.
  • 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.
  • Maintain regular contact with the enrollee to monitor and promote progress toward Care Plan goals; to assist the enrollee to navigate and access needed services: to provide ongoing monitoring of the implementation of the LTSS Care Plan; to monitor for changes in status including health, housing, natural supports and caregivers and to provide health and wellness coaching with a minimum of one face-to-face contact quarterly.     
  • Maintain all documentation required for the delivery of LTSS Community Partners services.

Education and Experience:

  • Experience Required: 
    • Three years of experience in a related capacity required with High School/GED
    • 1 year of relevant experience with Associates Degree & relevant experience
    • Bachelors Degree
      • Social Work, Human Services, Nursing, psychology, Sociology, or related field.
  • Must have strong written and oral communication skills and demonstrated computer skills
  • Prior experience in Outreach Coordination preferred.
  • Bi-lingual language capacity preferred.    

This is a benefits eligible position.  We offer a comprehensive benefits package including:
•    Medical, dental, vision insurance
•    Long term disability insurance
•    Life insurance
•    403b pension plan
•    Flexible spending account
•    Three weeks paid vacation
•    Twelve paid holidays
•    Generous earned sick time

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 135-year tradition of high quality.

Family Service Association is an Equal Opportunity Employer.  

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