Advocates

  • Care Coordinator

    Job Locations US-MA
    Job ID
    2018-4114
    Type
    Regular Full-Time
    Number of Hours Per Week
    40
  • Overview

    BHPMW Logo

     

    Be part of the rapidly changing health care system!  The Behavioral Health Partners of MetroWest (BHPMW) provides collaborative care coordination and wellness goal support to individuals with behavioral health and/or substance use needs, based on the recent transformation of Mass Health’s service delivery model.  The partnership is built on a collaboration among five community-based provider agencies: Advocates, Family Continuity, South Middlesex Opportunity Council (SMOC), Spectrum Health Systems, and Wayside Youth and Family Support Network, throughout MetroWest, Central and Northern Massachusetts. 

     

    The Care Coordinator will collaboratively coordinate and develop appropriate health care services for individuals who receive Behavioral Health care (“Enrollees”).

    Responsibilities

    • Utilize effective, dignified, empowering and creative engagement strategies to ensure Enrollees are at the center and lead in their BHCP services.
    • Conduct outreach and engagement activities with assigned Enrollees and engage them in enrolling in the BHCP program.
    • Complete comprehensive assessment in a collaborative manner with engaged Enrollees, under the supervision of the Clinical Care Manager, and with input from Care Team members and other stakeholders. Conduct annual re-assessments.
    • Develop a person-centered treatment plan with each engaged Enrollee, under the supervision of the Clinical Care Manager, and with input from Care Team members and other stakeholders. Update the treatment plan according to required timeframes.
    • Develop advanced directives, acute care plans, and/or crisis plans with engaged Enrollees as needed.
    • Work with engaged Enrollees to assemble Care Teams and facilitate all communication and coordination with the team.
    • Support engaged Enrollees during care transitions including attendance at discharge planning meetings, face to face meetings post discharge, ensuring linkages with all needed services and supports, and facilitating Enrollee participation in those services.
    • Assist the RN with medication reconciliation functions as required, such as information collection.
    • Provide health and wellness coaching to engaged Enrollees and assist them identifying and utilizing health and wellness supports in the community.
    • Connect engaged Enrollees to all needed services and supports including those that address social needs that affect health. Facilitate ongoing connection.
    • Collaborate with existing providers, Care Team members, state agency staff, and all other stakeholders and delivers CP supports and activities in accordance with Enrollee’s person centered treatment plan.
    • Meet expectations related to supporting the programmatically required number of Enrollees which may vary over time.
    • Demonstrate a proactive commitment to maintaining effective communication with staff, Enrollees, Care Team members and other collaterals, and other internal and external stakeholders and customers. Promote strong working relationships and excellent customer service.
    • Complete required trainings and other professional development activities.
    • Participate in BHCP team meetings and each engaged Enrollee’s Care Team to ensure effective communication among all disciplines and stakeholders involved in the person’s care.
    • Identify community resources and develop natural supports for client.
    • Consult with Clinical Care Managers, RNs and other CP Team members as needed around clinical, medical and other matters.

    Qualifications

    • Bachelor’s Degree in a field related to human services with a minimum of 1 year of experience; or High School diploma/GED with a minimum of 3 years of experience working with adults in a community-based and/or medical settings.
    • Ability to maintain personal and professional boundaries.
    • Strong skills in the areas of communication, follow through, collaboration, and customer service.
    • Computer skills, including proficiency with Microsoft Office Suite programs, with an emphasis on Word and Excel; ability to learn new systems; experience entering and working with data; and comfort and experience using mobile technologies.
    • Excellent organizational, time management, problem solving skills.
    • Ability to openly address and acknowledge issues of substance use and mental illness.
    • Excellent written and verbal communication.
    • Must hold a valid driver's license, have access to an operational and insured vehicle and be willing to use it to transport clients.
    • Strongly prefer a candidate that will have a demonstrated understanding of and competence in serving culturally diverse populations.

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