LTSS Care Coordinator

2 months ago

Jamaica Plain, United States JRI Inc Full time
Do you want to work for an agency that cares about clients and staff?

Do you want to work for an agency that has been voted a TOP PLACE TO WORK for 9 years in a row

Do you want to use your skills to help others? If you said yes to this, we at JRI are looking for you

JUSTICE RESOURCE INSTITUTE (JRI) seeks a detailed oriented LTSS Care Coordinator for the North Region (Lawrence, Lowell, and surrounding towns). LTSS Care Coordinator has flexible schedule with a hybrid work model, occasionally in the office, and otherwise remote work. This position can be either full-time or part-time.

This position is eligible for a $2K BONUS to new hire who speaks a second language used at LTSS program.

JRI is a Long-Term Services and Support Community Partner (LTSS CP) provider that partners with MassHealth contracted Accountable Care Organizations (ACOs) and Managed Care Organizations (MCOs) to promote coordination in the delivery and receipt of LTSS services to MassHealth members ages 3-21 with complex LTSS needs as a result of complex medical and behavioral health needs, intellectual and developmental disabilities. The role of the LTSS Care Coordinator is to provide outreach, care planning and coordination, care team facilitation and participation, support transition of care, provide health and wellness coaching, and connect engaged members with social services and community resources.The LTSS Care Coordinator will follow defined timelines in order to meet MassHealth requirements.The Care Coordinator is also responsible for documentation in the electronic health records system.

JOB DUTIES AND RESPONSIBILITIES:
The essential job duties/responsibilities of the position include but are not limited to the information listed below:

  • Serves as primary point of contact for LTSS care planning and coordination
  • Conduct comprehensive assessment and assess for social services needs using social services assessment tools
  • Develop, monitor and implement member care plans, including health care strategies, in partnership with member, their guardians/caregivers, and primary care team to ensure relevance and appropriateness
  • Collaborate closely with PCP and other providers regarding community resources, and assure appropriate referrals based on level of care needed to optimize outcomes and minimize risk.
  • Collaborate with ACO Plan, PCP and other health care Providers regarding changes in services, care transitions, crisis intervention; while focusing on continuity and quality of member care and potential efficiencies and cost-savings.
  • Communicate and collaborate with ACO teams and serve as a team resource.
KNOWLEDGE AND SKILLS:
  • Commitment to the right and ability of people served to live, work, have meaningful relationships and receive resources and supports needed in their community of choice
  • Knowledge of person-centered and strengths-based principles and modalities
  • Knowledge of health promotion and medical care coordination techniques
  • Knowledge of motivational interviewing, stage of change and harm reduction techniques
  • Knowledge of trauma-informed and culturally competent services
  • Sensitivity to cultural, religious, ethnic, disability and gender issues
  • Knowledge of empowerment and self-advocacy techniques
  • Knowledge of available community, health, and mental health services and resources
  • Ability to make independent judgments and decisions
  • Ability to work in a professional and confidential capacity
  • Ability to work independently as well as part of a multi-disciplinary team
  • Ability to navigate and utilize electronic health records
  • Strong organizational and time management skills with triaging priorities
  • Effective relationship management and team building skills
REQUIREMENTS:
  • A Bachelor's degree in social work, human services, psychology, sociology, or related field; or Associate's degree with a minimum of 2-3 years of related professional experience
  • Experience working with people with disabilities, and complex Long-Term Services and Support and/or Behavioral Health needs
  • Maintains valid driver's license as driving is a requirement for this position using a personal vehicle.
  • Background and driving record checks will be performed.
WHY JRI?
  • Be who you are JRI is strongly committed to providing an inclusive, diverse and welcoming environment for our employees and the people we serve.
  • Access to our excellent Blue Cross Medical, 100% employer-paid Delta Dental, and Vision benefits. Additional monetary benefit if you are covered by another non-state/ government sponsored health plan.
  • Retirement benefits including 401K matched up to $800 a year and Pension Plan after 5 years of employment.
  • Professional development opportunities such as tuition reimbursement up to almost $4000 per year and discounted tuition rates to select partnership colleges and universities
  • Professional License Reimbursement
  • Wellness benefits including access to employee resource groups (including multicultural affinity groups, LGBTQ+ advocacy, employee engagement groups, etc.), self-care resources, and an Employee Assistance Program.
  • Generous paid time off up to 19 days plus 11 Holidays for full time employees in your first year and much more
JRI PROVIDES THE TRAINING SO THAT:
  • YOU will work in partnership with clients and their families to manage, negotiate, and collaborate with multidisciplinary teams with the goals of minimizing duplicative efforts, promoting integrated care, ensuring quality and continuity of care, and supporting the values of a person-centered LTSS care plan.
  • YOU will be responsible for social needs assessment, LTSS care planning, care coordination, support in care transitions, and health and wellness coaching.
  • YOU will engage in outreach to develop and manage community and social services connections.


JRI is strongly committed to providing an inclusive, diverse and welcoming environment for our employees and the people we serve. Persons from diverse backgrounds including women, communities of color, the LGBTQ community and people with disabilities are encouraged to apply. JRI is an equal opportunity employer.

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