MCCN Care Coordinator

4 weeks ago

Brockton, Massachusetts, United States Brockton Area Multi-Servi Full time
Job Description

At Brockton Area Multi-Services, Inc., we are seeking a highly skilled MCCN Care Coordinator to join our team. As a Care Coordinator for MCCN, you will play a vital role in providing LTSS care coordination activities to youth and adult Enrollees of MCCN, facilitating the appropriate delivery of health care services and improving health outcomes.

Responsibilities:

1. Collaborate with care management, medical teams, and other providers to provide LTSS care management services.
2. Work with the care team to complete and utilize Comprehensive Assessment results, and develop or update the LTSS Person Centered Treatment Plan within 122 days of assignment.
3. Ensure the LTSS Person Centered Treatment Plan meets EOHHS requirements and notify the care team of any changes to the Assigned or Engaged Enrollee's functional status.
4. Ensure the Assigned or Engaged Enrollee receives necessary assistance and accommodations to prepare for, fully participate in, and direct the care planning process.
5. Provide education on LTSS terms and concepts, including functional status, family involvement, self-directed care options, and available LTSS services or programs.
6. Inform the Assigned or Engaged Enrollee about their options for specific LTSS services and programs and providers that may meet their needs.
7. Assess the Assigned or Engaged Enrollee for social services and identify community and social services and resources that may support their health and wellbeing.
8. Coordinate all aspects of service delivery and promote integration with health care providers, BH providers, LTSS providers, and community/social service providers.
9. Participate in Enrollee's care team meetings to ensure effective communication among all disciplines involved in individual's care.
10. Provide health and wellness coaching as directed by the Engaged Enrollee's care team and as indicated in the Enrollee's LTSS Person Centered Treatment Plan.
11. Maintain regular contact with Assigned or Engaged Enrollee to monitor and coordinate LTSS Person Centered Treatment Plan, including quarterly face-to-face meetings.
12. Conduct face-to-face home visits with the Enrollee on an initial and quarterly basis, and complete in-person follow-up after discharge visits within 7 days following an Enrollee's inpatient discharge or transition to a community setting.
13. Support transitions of care by completing a follow-up within 7 calendar days following an Enrollee's emergency department (ED) discharge, and coordinate clinical services and other supports for the Enrollee as needed.
14. Contact the Enrollee's providers and collaterals to ensure accurate contact information when Assigned or Engaged Enrollees become unreachable.

Qualifications:

· BA in social work, human services, nursing, psychology, sociology, or related field from an accredited college/university, or an Associate's degree and at least one year of professional experience in the field, or at least three years of relevant professional experience.
· Experience working with individuals with complex LTSS needs and credentialed as a community health worker, health outreach worker, peer specialist, or recovery coach desired. Care Coordination and Behavioral Health experience preferred.
· Ability to use Electronic Health Records (EHR) Systems to document and coordinate services.
· Strong interpersonal skills, including developing working relationships with a variety of individuals in different contexts, and ability to communicate effectively verbally and in writing.
· Strong organization skills, including attention to detail, multi-tasking, prioritization, analytical, problem-solving, and team skills.
· Strongly prefer a demonstrated understanding of and competence in Health Equity and serving culturally diverse populations.
· Commitment to MCCN values and mission.
· Ability to travel on a regular basis, with a valid driver's license and access to an automobile.
· Ability to read and speak English, with fluency in other languages, including Spanish, Cape Verdean Creole, Haitian Creole preferred.
· Strongly preferred experience in Microsoft Products and software, including Teams, Excel, Word, Outlook, etc.
· Strong computer knowledge, including proficiency in contemporary Windows operating systems and Windows office suites, with an emphasis on Word and Excel, and ability to learn new systems, experience entering and working with data, and comfort and experience using mobile technologies.
· Knowledge regarding psychiatric rehab and understanding of recovery model.
· Strongly prefer a demonstrated understanding of and competence in Health Equity and serving culturally diverse populations.

At Brockton Area Multi-Services, Inc., we are committed to Diversity, Equity, Inclusion, Justice, and Access for all, and to creating a holistic system of care that meets people where they are. We strive to offer valuable benefits that promote a healthy work/life balance and add value to our employees' lives. Our comprehensive benefits include a generous Time Off Package, Highly Specialized Paid Trainings, Health and Dental Insurance, Life, Short Term and Long Term Disability Insurance, 403B plan with discretionary match, Wellness Activities, Employee Assistance Program, and Career Development Opportunities. We are an equal opportunity and Affirmative Action Employer, encouraging diversity in the workplace. All qualified applicants will receive consideration for employment without regard to their race, color, creed, religion, ancestry, national origin, sex, sexual orientation, gender identity, age, marital status, family responsibilities, pregnancy, genetic information, protected veteran or military status, and regardless of whether the qualified applicants are individuals with disabilities.

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