The Community Health Worker (CHW) provides care coordination and 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 CHW collaborates with the 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 CHW 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 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.

SIGN ON BONUS: $1.5K

• Outreach to and engage Enrollees of an ACO plan as referred to CP Program.
• Coordinate the completion of the Comprehensive Assessment (CA).
• Conduct initial and ongoing risk assessment; design personal crisis management plans, relapse prevention and harm reduction strategies with members who have been identified as behaviorally complex in collaboration with team LPHAs.
• Coordinate the development, implementation, and ongoing review of the Person Centered Treatment Plan (PCTP) inclusive of any LTSS and / or SDH needs or goals of the Enrollee.
• Drive referrals regarding connections to any community or social services that align with the Enrollees needs and goals.
• Submit CA, PCTP, and all PCTP updates in accordance with the data sharing agreement CP and ACO/MCO Plan.
• Collaborate closely with PCP and other providers, including but not limited to community resources, to assure appropriate referrals based on level of care needed to optimize outcomes and minimize risk.
• Communicate and collaborate with ACO/MCO teams and serve as a team resource.
• Collaborate with ACO Plan, PCP, and other health care providers regarding changes in services, care transitions, and crisis intervention while focusing on continuity and quality of client care and potential efficiencies and cost-savings.
• Obtain required Prior Authorization from ACO/MCO Plan for relevant/necessary services.
• Manage all care transitions through collaboration with Enrollee, community provider staff, ICT, and hospital staff to ensure a safe discharge plan and a well-coordinated implementation of that plan.
• Ensure for medication review and reconciliation as triggered by a care transition or by a medication change through an outpatient medical or psychiatric visit.
• Perform other related duties, as required.

Knowledge and Skills:
• Strong commitment to the right and ability of people served 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 prevalence with adults with SMI/SUD
• Knowledge of health promotion and clinical care coordination techniques
• Knowledge of motivational interviewing, stage of change, and harm reduction techniques
• Knowledge of trauma-informed and culturally responsive services
• Sensitivity to the cultural, religious, ethnic, disability, and gender issues
• Skills and competence to establish supportive trusting relationships with Enrollees
• Knowledge of human, legal, civil rights, community, and other resources
• Knowledge of empowerment and self-advocacy techniques
• Knowledge of available community health, mental health, and SUD services and resources
• 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 and as member of a multidisciplinary team

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.