The Clinical Care Manager (CCM) provides intensive care coordination and clinical care management for MassHealth Members with complex medical and behavioral health needs who are enrolled in an Accountable Care Organization (ACO) or Managed Care Organization (MCO) plan. The CCM collaborates with their respective Community Partner team and the clinical staff of each Enrollee’s ACO/MCO’s plan to minimize duplicative efforts, promote integrated care, ensure quality and continuity of care, and support the values of person-centered planning, Community First and SAMHSA Recovery Principles. The CCM is at the helm of organizing and coordinating resources and services in response to the Enrollee’s healthcare needs across multiple settings, and inclusive of both LTSS and Social Determinants of Health (SDH) needs. This role drives outreach and engagement, assessment and care planning, care transitions, health and wellness coaching, as well as community and social services connections in partnership with Enrollees and their care teams.

• Outreach to and engage enrollees enrolled in ACO and referred for CP program.
• Conduct comprehensive assessment of enrollees including the medical, psychiatric and social issues of enrollees served.
• Review/sign off on medical component of comp assessment of Care Team enrollees.
• Organize and facilitate the effective functioning of the Interdisciplinary Care Team (ICT), including coordinating meetings, facilitating communication, and documentation.
• Monitor the enrollee’s health status and needs and provide nursing and medical care coordination, including revising health related treatment goals and plans in collaboration with the enrollee and the team.
• Coordinate the development, implementation, monitoring, and review of the enrollee care plans, including health care strategies.
• Collaborate closely with PCP and other Providers including, but not limited to community resources, and assure appropriate referrals based on level of care needed to optimize outcomes and minimize risk.
• Collaborate with ACO Plan, PCP, and other health care Providers regarding changes in services, 
care transitions, crisis intervention; while focusing on continuity and quality of enrollee care and potential efficiencies and cost-savings.
• Conduct medication reviews and reconciliation including adjustment by protocol.
• Communicate and collaborate with ACO teams and serve as a team resource.
• Follow up of an enrollee’s admission to a planned or unplanned medical or psychiatric inpatient stay, (including hospital, Rehab facility, shelter, substance abuse programs), and collaborate with enrollee, care team staff, ICT and hospital staff to coordinate safe inpatient discharges. 
• Perform other related duties, as assigned.

Knowledge and Skills:
• Strong commitment to the right and ability of people served by ACCS to live, work, have meaningful relationships and receive the clinical treatment, resources and supports needed to thrive in their community of choice
• Knowledge of clinical treatment principles and modalities, best practices and evidence-based practices, including Motivational Interviewing; Harm Reduction and Addiction Treatment; Screening, Brief Intervention, Referral and Treatment (SBIRT); Housing First; Stages of Change; Seeking Safety and Cognitive Behavioral interventions
• Knowledge of engagement strategies
• Knowledge of crisis prevention, crisis intervention, and risk management strategies
• Knowledge of recovery-oriented, person-centered and strengths-based values and principles and modalities, and knowledge of Peer Support principles and evidence-based practices, including the ethical standards of Certified Peer Specialists and Wellness Recovery Action Plans (WRAP), empowerment and self-advocacy techniques
• Knowledge of the effects of prejudice including internalized negative attitudes about oneself, discrimination, and oppression of people with psychiatric disorders, and the effects of poverty
• Knowledge of trauma-informed and culturally competent services
• Sensitivity to the cultural, religious, ethnic, disability and gender issues of PS
• Knowledge of human, legal, and civil rights of PS
• Knowledge of emergency services and acute care systems
• Knowledge of community based mental health, health care, care coordination and other services and resources available to PS
• Knowledge of health risks of psychiatric disability
• Skills and competence to formulate effective Treatment Plans, and to train paraprofessional staff to implement aspects of the plan
• Ability to collaborate effectively with other Team members to address the needs of PS in the Treatment Plan
• Ability to form supportive, trusting relationships with PS
• Knowledge of formal and informal assessment practices
• Knowledge and use of different communication and learning styles
• Ability to make independent judgments and decisions
• Ability to work in a professional and confidential capacity
• Knowledge of personal computer applications and equipment
• Extensive knowledge of documentation standards and requirement

Established in 1977, Vinfen is a nonprofit, health and human services organization and a leading provider of community-based services to individuals with mental health conditions, intellectual and developmental disabilities, brain injuries, and behavioral health challenges. Our services and advocacy promote the recovery, resiliency, habilitation, and self-determination of the people we serve. Vinfen's 3,200 dedicated employees are experienced, highly-trained professionals who provide a full range of supportive living, health, educational, and clinical services in 318 programs throughout Massachusetts and Connecticut. For more information about Vinfen, please visit www.vinfen.org/careers

My Vinfen. My Community. My Job.

Vinfen is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, pregnancy, sexual orientation, gender identity, national origin, age, protected veteran status, or disability status.