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South Middlesex Opportunity Council Care Coordinator- Worcester in Worcester, Massachusetts

Essential Functions:

  • 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.

  • Strictly adhere to all HIPPA regulations and maintain confidentiality at all times.

  • 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.

  • Attend and actively participate in all required training.

  • Learn all BHCP policies, procedures, protocols, plans and evidence based practices and deliver CP supports and activities in compliance with them.

  • Develop knowledge about all focus populations.

  • Complete all required documentation/notes/reporting in a timely manner.

  • Attends and actively participates in supervision and staff meetings.

  • Consults with Clinical Care Managers, RNs and other CP Team members as needed around clinical, medical and other matters.

  • Provide on-call coverage, as needed.

  • Ensure that all clients are treated with dignity and respect in accordance with BHPMW’s Human Rights Policy.

  • Perform all duties in accordance with the agency’s policies and procedures.

  • Strictly follow all agency Performance Standards.

Please note: The essential functions listed in this section are not limited only to the tasks listed and may include other duties as assigned.

Qualification/Education/Experience:

  • BA/BS 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

  • Excellent verbal and written communications skills.

  • Strong skills in the areas of communication, follow through, collaboration, and customer service.

  • Strong Computer skills proficiency in contemporary Windows operating systems and Windows office suites 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.

  • Knowledge regarding psychiatric rehab and/or substance use and understanding of recovery model.

  • Must be able to perform each essential duty satisfactorily.

  • Strongly prefer that a candidate will have a demonstrated understanding of and competence in serving culturally diverse populations.

  • Must hold a valid drivers’ license. Must have access to an operational and insured vehicle and be willing to use it to transport members.

  • Must have ability to read English and communicate effectively in the primary language of the program to which he/she is assigned.

Physical Demands:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

General requirements:

  • Full upper extremity range of motion

  • Full lower extremity range of motion

*Continuous: Communication

*Frequent: Standing, sitting, walking

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