• Care Coordinator

    Job Locations US-MA | US-MA
    Job ID
    Regular Full-Time
    Number of Hours Per Week
  • Overview

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    The MCCN Care Coordinator will provide coordinated Long Term Services and Supports (LTSS) Care Management services as an integrated member of care management team to youth and adult Enrollees in need of services.


    • Work collaboratively and effectively with care management, including Enrollee, medical team and other providers to provide LTSS care management services.
    • Utilize the Comprehensive Assessment results from the ACO or MCO, and work with Enrollee to develop or update the LTSS Care Plan.
    • Ensure that the LTSS Care Plan meets the requirements of EOHHS and notify the ACO or MCO if changes have occurred to Assigned or Engaged Enrollee’s functional status, including Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) needs, since the completion of the Comprehensive Assessment.
    • Ensure the Enrollee receives necessary assistance and accommodations to prepare for, fully participate in, and to the extent preferred, direct the care planning process.  Ensure that the Enrollee receives assistance in understanding LTSS terms and LTSS concepts, including but not limited to information on their functional status; how family members, social supports and other individuals of their choosing can be involved in the care planning process; self-directed care options and assistance available to self-direct care; and LTSS services or programs that are available to meet their needs and for which they are potentially eligible.
    • Inform the Enrollee about his or her options for specific LTSS services and programs and providers that may meet their needs.
    • Conduct an assessment of the Enrollee for social services and identify community and social services and resources that may support the health and wellbeing of the Enrollee.
    • Conduct assessment for Flexible Services for all Enrollees who are enrolled in an ACO.  If Flexible Services are identified, make recommendation to ACO for approval.
    • Provide LTSS subject matter expertise to health care, behavioral health, and social services providers.
    • Coordinate all aspects of service delivery and promote integration with health care providers, BH providers, LTSS providers and community/social service provides that the Enrollee may be receiving, as outlined in the LTSS Care Plan.
    • Participate in Enrollee’s care team meetings to ensure effective communication among all disciplines involved in individual’s care.
    • Provide health and wellness coaching as directed by the Enrollee’s care team and as indicated in the Enrollee’s LTSS Care Plan.
    • Maintain regular contact with Enrollee to monitor and coordinate LTSS Care Plan including quarterly face-to-face meetings.
    • Provide transition planning and transition coordination to Enrollee including follow-up support post discharge.


    • Bachelor’s Degree in related field from an accredited college/university; or an Associate’s Degree and at least one year professional experience in the field; or at least three years of relevant professional experience.  Care Coordination experience preferred. Previous experience with individuals who hold complex LTSS needs and bilingual communication skills are a strong plus!
    • Ability to use Care Management Software to document and coordinate services.
    • Experience in navigating individual and family service systems and demonstrated the capacity to work collaboratively and effectively with families and community-based colleagues.
    • Strong interpersonal skills regarding developing a working relationship with a variety of individuals in a variety of context.
    • Strong organizational skills with attention to detail, multi-tasking and prioritization skills, and ability to thrive in a team-based environment.
    • Excellent written and verbal communication.
    • Must hold a valid driver's license, have access to an operational vehicle and be able to commute and travel for work.
    • Strongly prefer a candidate that will have a demonstrated understanding of and competence in serving culturally diverse populations.


    Advocates is an EOE/D/F/M/V.


    Why Should I Consider a Career in Human Services?

    Our Team members are dedicated to engaging and empowering individuals by forming lasting relationships, collaboratively achieving personal goals, offering creative solutions to everyday and complex situations, and actively listening.  We exercise independent judgement and contribute to the overall success and benefit of the Team.


    Is Human Services a Fit for Me?

    Successful Team members are open-minded, eager and compassionate, and will exercise solid, independent judgement while fostering trustworthy relationships with the individuals that we serve.  We put the individual first.


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