The Health Outreach Worker collaborates with the Clinical Care Manager (CCM) to provide care coordination for One Care enrollees with complex healthcare needs. The Health Outreach Worker collaborates with Vinfen’s CBFS teams and the One Care Plan’s clinical staff to maximize coordination and integration of care. The Health Outreach Worker also provides administrative support to the CCM.

The essential job duties/responsibilities of the position include but are not limited to the information listed
below:
• In collaboration with the Clinical Care Manger (CCM), provide outreach to and engagement of clients enrolled in One Care.
• Maintain and update all client documentation including health assessments and care plans in Vinfen’s systems and in the One Care Plan’s electronic medical record as applicable.
• With the CCM, facilitate the implementation and monitoring of the clients’ Individual Care Plans (ICP)
• Collaborate closely with CCM, PCP and including, but not limited to other healthcare providers and community resources, and facilitate appropriate referrals based on level of care needed to optimize outcomes and minimize risk.
• Collaborate with CCM, One Care Plan, PCP and other health care providers regarding changes in services, care transitions, crisis intervention.
• Under the supervision of the CCM, conduct home and community-based visits as required

• Provide support and education to clients to enhance health and wellness self-management.
• Assist participants in accessing health care services, through training or by directly accompanying or transporting them to health care visits as requested by the CCM
• Serve as a resource for clients, families, and outside agencies requesting information.
• Maintain appropriate written and oral communication.
• Participate in quality assessment and quality improvement within the scope of responsibilities including data collection, reporting, analyses, and quality management activities designed to improve care and increase effectiveness of the service model.
• Actively participate in the evaluation of own performance.
• Seek to maintain a constructive work environment and maintain effective communication with others.
• Perform other related duties, as required.

Knowledge and Skills:
• Excellent organizational, time management, and problem-solving skills
• Ability to function effectively as part of a multi-disciplinary team
• Knowledge regarding psychiatric rehabilitation and recovery
• Effective oral and written skills
• Strong interpersonal and customer relations skills
• Effective teaching skills
• Knowledge of business communication formats (correspondence, memos, minutes, reports, financials, etc.)
• Knowledge of business etiquette and practices
• Knowledge of grammar and punctuation
• Ability to compose routine correspondence
• Specific knowledge of: Microsoft Office, including Word, Excel, and Access, Outlook Vinfen’s internet access applications
• Department-specific applications
• Knowledge of recordkeeping systems
• Organization and quantitative skills Repeated from above
• Ability to communicate in a positive, courteous, and professional manner
• Ability to exercise judgment & discretion in dealing with individuals and confidential matters
• Knowledge of Vinfen’s mission, organization, and services

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 two years of experience in Human Services is required. Experience working with people with psychiatric disabilities, co-occurring disorders preferred. Care coordination experience preferred.

Preferred /Required Education:
A high school diploma or equivalent is required; Bachelor’s degree preferred. In some cases, experience may be substituted for academic training.

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 six months 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:
First Aid required within two weeks of hire
CPR required within two weeks of hire