The Care Coordinator (CC) 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 CC 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 CC 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. The overall goal is improving the quality of care which leads to cost savings and improved health outcomes and experiences for MassHealth Members.

The essential job duties/responsibilities of the position include but are not limited to the information listed below:
● Provides outreach to and engages Enrollees referred to CP Program. 
● Supports team by focusing on “hard to reach” individuals.
● Coordinates and plans coordination and co-location of CP services with both internal and external partners.
● Drives and obtains referrals regarding connections to community or social service partners that 
align with the needs and goals of target population (Social determinants of health).
● Works with PCP offices, specialty providers and acute care settings to generate new referrals for CP teams.
● Collaborates 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.
● Communicates and collaborates with ACO/MCO teams and serve as a team resource. 
● Manages a modified caseload which includes the development and completion of Comprehensive Assessments, risk assessments and complex care planning.
● Leads care transitions for “hard to reach” enrollees 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. 
● Performs other duties, as required.

Knowledge and Skills:
• Ability to collaborate as a member of multidisciplinary and cross-functional teams
• Ability to function as an agent of change
• Ability to make independent judgements and decisions
• Ability to work in a professional and confidential capacity
• Ability to triage/balance competing priorities
• Ability to function under pressure in fast passed health and human services environments
• Ability to be flexible, open and responsive to ongoing industry changes
• Ability to articulate and communicate the Community Partners program’s mission
• Ability to represent the organization in a variety of circumstances and forums
• Ability to identify opportunities and obstacles and develop effective and creative solutions
• 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, strength 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 trauma-informed and culturally responsive services
• Sensitivity to 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

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.

Typical Requirements:
Minimum of 3 years care management experience preferred. Experience working with people living with SMI and/or SUD. Preference given to bi-lingual/bi-cultural applicants and those with lived experience of BH conditions.

Preferred /Required Education:
A high school diploma or equivalent is required; BA/BS in human-services related field preferred.

Driving Requirements:
Driving is a requirement for this position using either a Vinfen van or personal vehicle. If using a personal vehicle, you must possess and maintain adequate insurance as well as maintain a safe driving record which is subject to annual checks. A valid driver's license must be presented at the time of employment. Incumbents must be at least 21 years of age, have maintained a valid US driver's license for at least one year, and must be able to pass a driver's screening background check.

Physical Effort
Ability to stand, walk, bend, kneel, stoop, crouch, crawl, climb as this is a very physically active position. 
Must be able to lift at least 25 pounds using proper lifting techniques or the use of a two-person lift. 
Ability to operate a computer and other office equipment such as a calculator, copier, and printer. 
Ability to sit, reach, climb stairs, and maneuver through narrow spaces or hallways.

Ability to assist clients with tasks of daily living.

Ability to remain in a stationary position 50% of the time as needed. 
Ability to bend, reach, file, sit, stand, and move around the facility.

Ability to speak, hear, and communicate with clients, staff, and external representatives.

Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and ability to adjust focus. 

For positions in day programs or group residences, the ability to assist in routine living activities including cleaning, meal preparation, vacuuming, shoveling, and grocery shopping.

Required Certifications:
CPR required within two weeks of hire
First Aid required within two weeks of hire
Safety Care is required within 90 days of hire
NET Required
CCP NET Trainings required within 90 days of hire