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Center for Human Development Care Coordinator - LTSS in Pittsfield, Massachusetts

The Long Term Services and Supports Care Coordinator (LTSS Care Coordinator) is tasked with improving Enrollee health outcomes and reduce Enrollee cost of care. The LTSS Care Coordinator is responsible for implementing all appropriate required Enrollee level MassHealth contractual and pay-for-performance requirements. The LTSS Care Coordinator participates in multi-disciplinary care team meetings. Assist Enrollee in accomplishing goals of the LTSS Care Plan. Examples or duties may include the following: - Collaborate with the Enrollee?s care team (registered nurse, PCP, PCA, medical director, behavioral health specialists, social workers, etc.). - Encourage Enrollee to follow treatment recommendations through support, health and wellness education, and advocacy. - Link Enrollees with resources and encourage them to use them to their advantage. - Utilize recovery strategies such as Motivational Interviewing, Harm Reduction and Strength Based approaches to support enrollees in attaining stated goals. - Conduct visits in the home or in other locations in the community to provide guidance, support, education and coaching. Follow-up by telephone as necessary. - Accompany Enrollees to medical appointments as requested; facilitates effective navigation of the health care system Adhere to MassHealth contractual requirements. - Complete minimum monthly contact with Enrollees and document the qualifying activity by utilizing appropriate activity codes and related modifiers as specified by MassHealth. o Examples of Qualifying Activities include the following: Outreach, assessment, care planning, care transitions and discharge follow-up, connection to community, social service, and flex supports, and coaching. - Completion of a Care Plan and Social Service Assessment annually. This includes coordination with the Enrollee?s Medical Home. - Utilization of the EMR Event tracking system. This includes, but is not limited to checking for daily Alerts, tracking updates of the Care Plan status, and documentation of the ACO Assessments. The LTSS Care Coordinator will complete duties related to pay-for-performance metrics as determined by MassHealth, EOHHS, and CMS. Examples of these duties are as follows: - Assist Enrollees in having an annual primary care visit. - Complete a Care Plan annually. The Care Plan must be submitted to PCP no less than 30 days prior to expiration on 1-year requirement. - When requested, perform Engagement tasks including, but not limited to, outreach and obtaining initial enrollment paperwork. - Complete a face-to-face visit within 3 business days to Enrollees after acute or post-acute stay as requested. - Ensure that Enrollee has an annual oral health evaluation. Maintain the ability to adapt and remain flexible with changing MassHealth, EOHHS, and CMS requirements and ongoing clarifications of the Community Partner Program. Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor?s legal duty to furnish information. 41 CFR 60-1.35(c)