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 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 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 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.

 Job Duties and Responsibilities:

The essential job duties/responsibilities of the position include but are not limited to the information listed below:

• Outreach to and engage Enrollees of an ACO plan as referred to CP program.
• Coordinate the completion of the Comprehensive Assessment (CA).
• Review/sign off on Comprehensive Assessment, as indicated.
• 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.
• 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.
• Organize and facilitate the effective functioning of the Interdisciplinary Care Team (ICT), including coordinating meetings, facilitating communication and documentation.
• 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.
• 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 client care and potential efficiencies and cost-savings.
• Manage 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 duties, as required.

Why Vinfen? We are committed to you! We offer great training, great benefits, career growth and job security!

Our comprehensive and generous benefits package includes:

• A fully funded, employer-sponsored retirement plan that requires no employee contribution as well as an employee-funded 403(b) plan
• First-rate Medical, Dental and Vision plans that are open all employees scheduled to work 30 hours per week or more. Plus, we offer a generous employer contribution toward the cost of medical insurance!
• Employer-paid Life, Accidental Death & Dismemberment and Long-Term Disability Insurance (no cost to you!)
• Employer-paid Short-Term Disability Insurance along with the option to purchase additional, voluntary, Short-Term disability insurance
• Flexible Spending Reimbursement Accounts (Health and Dependent care)
• Voluntary Term, Whole Life, Accident and Critical Care Insurance
• Generous paid time off (Employees scheduled to work 20 hours or more per week):
• 15 days of Vacation per year
• 11 Paid Holidays
• 10 Sick Days per year
• 3 Personal Days per year
• Educational Assistance and Remission Programs
• $500 Employee Referral Bonus with no annual cap!
• Other generous benefits including discounted YMCA memberships, access to discounted movie tickets and more!

About Us:

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 3,500 dedicated employees are experienced, highly-trained professionals who provide a full range of supportive living, health, educational, and clinical services in over 550 sites throughout Massachusetts and Connecticut. For more information about Vinfen, please visit www.vinfen.org/careers.

My Job. My Community. My Vinfen.

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.

• Master's Degree in Social Work, Psychology or related along with professional licensure (LCSW, LICSW, LMHC) in state of service required. Strong preference for license to practice independently (LICSW, LMHC)
• A minimum of 5 years of clinical and case management experience preferred, experience working with people living Serious Mental Illness and/or Substance Abuse Disorder strongly preferred
• Strong organizational and collaboration skills
• Ability to prioritize work tasks and work both independently and as part of a multi-disciplinary team
• Ability to effectively represent the organization in a variety of circumstances and forums

Driving is a requirement for this position. You must have access to a fully insured, licensed vehicle that you are willing to use in the course of your daily work. You must be willing to transport clients in your personal vehicle.

All candidates for this position must be a least 21 years of age and be able to pass a CORI, driving record, reference, educational and professional licensure as well as multi-state background check.