The Clinical Care Manager (CCM) provides care coordination and clinical management for One Care enrollees with complex healthcare needs. The Clinical Care Manager collaborates with Vinfen’s ACCS teams and the One Care Plan’s clinical staff to maximize coordination and integration of care. The CCM will be at the helm of organizing and coordinating resources and services in response to the individual healthcare needs across multiple settings. 

• Provides outreach to and engage clients enrolled in One Care.
• Conducts comprehensive health assessment of enrolled clients including the medical, psychiatric, and social issues of clients served. 
• Organizes and facilitates the effective functioning of the Interdisciplinary Care Team (ICT), including coordinating meetings, facilitating communication, and documentation.
• Monitors the client’s health status and needs and provides nursing and medical care coordination, including revising health related treatment goals and plans in collaboration with the client and the team.
• Coordinates the development, implementation, monitoring, and review of the Individual Care Plan (ICP), including health care strategies.
• Submits all ICP revisions in accordance with the data sharing agreement between Vinfen and One Care Plan.
• Collaborates closely with PCP and other providers including, but not limited to, community resources, and assures appropriate referrals based on level of care needed to optimize outcomes and minimize risk.
• Collaborates with One Care Plan, PCP, and other health care providers regarding changes in services, care transitions, crisis intervention, while focusing on continuity and quality of client care and potential efficiencies and cost-savings.
• Integrates the expertise of a Long-Term Services (LTS) Coordinator, and arranges for LTS Coordinator participation in the assessment, care planning, and ongoing ICT activities, if and when applicable.
• Provides self-management education and training to clients, while honoring client choices, maintaining holistic focus, and educating and supporting clients’ families and friends (following HIPAA authorization by client) regarding clients’ needs and preferences as they relate to health 
care.
• Conducts medication reviews and reconciliation, including adjustment by protocol.
• Supervises Health Outreach Worker. 
• Communicates and collaborates with ACCS teams and serves as a team resource.
• Obtains required Prior Authorization from One Care Plan for all relevant and medically 
necessary services.
• Responsible for follow up of a client’s admission to a planned or unplanned medical or psychiatric inpatient stay (including hospital, Rehab facility, shelter, substance abuse programs), and collaborates with client, Vinfen staff, ICT, and hospital staff to coordinate safe inpatient discharges.
• Maintains frequent client contact, as indicated.
• Performs other related duties, as required.

Knowledge and Skills:
• Strong knowledge base in clinical and financial aspects of care
• Strong commitment to the right and ability of people served by Vinfen to live, work, have meaningful relationships, and receive the resources and supports needed in their community of choice 
• Knowledge of person-centered, strengths-based, recovery-oriented values and principles, and modalities
• Knowledge of clinical and psychiatric rehabilitation values, principles, and techniques
• Knowledge of health risks of psychiatric disability 
• Knowledge of health promotion and medical care coordination techniques
• Knowledge of motivational interviewing, stage of change, and harm reduction techniques 
• Knowledge of trauma-informed and culturally competent services 
• Sensitivity to the cultural, religious, ethnic, disability, and gender issues 
• Skills and competence to establish supportive trusting relationships with program clients
• Knowledge of human, legal, civil rights, community, and other resources
• Knowledge of empowerment and self-advocacy techniques
• Knowledge of teaching modalities
• Knowledge of available community health and mental health services and resources
• Knowledge and use of different communication and learning styles and supervisory techniques
• Knowledge of formal and informal assessment practices
• Knowledge of data-driven decision-making processes and ability to encourage others to use data analysis, as needed
• Ability to triage/balance competing priorities
• Ability to make independent judgments and decisions
• Ability to work in a professional and confidential capacity
• Ability to work independently as well as part of a multi-disciplinary team
• Knowledge of personal computer applications and equipment
• Knowledge of documentation standards requirements

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.