TheLong Term Services and Supports (LTSS) Care Coordinator (CC) provides LTSS care planning, coordination and advocacy for MassHealth Members withcomplexhealthcare needs who are enrolled in an Accountable Care Organization(ACO) or Managed Care Organization (MCO) plan.The CC collaborateswith the respective Community Partner teamandthe clinicalstaffof each Enrollee's ACO/MCO's plan tominimize duplicative efforts, promote integratedcare, ensure quality and continuity of care, and support the values of person centered planning, Community First and Principles of a Valued Life.The CC is at the helm of organizingandcoordinatingresourcesandservicesinresponsetotheEnrollee'sLTSS and Social Determinants of Health needsacrossmultiple settings. This role drives outreach and engagement, social needs assessment, LTSS care planning and care coordination, support of care transitions, health and wellness coaching, as well as community and social services connections in partnership with Enrollees and their designated care teams.
Serve as primary point of contact for LTSS care planning and coordination
Review results of Comprehensive Assessment completed by ACO/MCO and notify ACO/MCO of any changes
Assess Enrollee for social services using EOHHS approved social services assessment
Inform Enrollee of options for specific LTSS services, programs, and providers that best meet identified needs
Identifycommunity and social services to support health and wellbeing of Enrollee
Develop LTSS Care Plan in partnership with Enrollee and their designated Care Team
Support Enrollee's LTSS care need decisions and LTSS integration in the Care Plan
Implement and monitor Care Plan to ensure LTSS are relevant and appropriate
Update Care Plan annually, as needed to reflect changing needs, or at Enrollee request
Promote and facilitate the integration of Enrollee's LTSS care across physical, behavioral and LTSS areas as well as social services and Flexible Services as applicable
Assess Enrollee for Flexible Services - if identified, request approval from ACO
Coordinate and facilitate frequent communication among Enrollee, Care Team, Providers including coordinators of other state agencies, and Enrollee's ACO/MCO
Educateenrollees'familiesandfriends(perHIPAAauthorization of Enrollee)regardingenrollee'needsandpreferencesasrelated to overall health and well-being
Support care transitions through collaboration
Ensure all Enrollees are consistently provided with trauma informed and cultural responsive services
Complete Monthly Qualifying Activities as required
Document all care coordination activities in Enrollee's electronic record
A COVID-19 vaccination is a requirement of the position. One COVID-19 shot is acceptable, contingent on the individual receiving the second shot within the allotted time frame.
Knowledge of accessing LTSS services and resources including but not limited to home-based services, DME, transportation, respiratory therapy, and adult foster care
Ability to collaborate as a member of multidisciplinary and cross-functional teams
Ability to adjust quickly to frequent caseload census changes
Ability to independently organize time to meet deadlines and effectively manage high caseload numbers
Ability to function as an effective change agent
Ability to function under pressure in fast paced health and human services environments
Ability to be flexible, open and responsive to ongoing industry changes
Ability to articulate and communicate the Community Partner program's mission
Ability to identify opportunities and obstacles and develop effective, creative solutions
Appreciation of the impact SDH and stigma have on the very day lives of persons served including health access, experience and outcomes
Ability to work independently and access team knowledge and resources as needed
Minimumof3yearscasemanagementexperiencedpreferred.Effectiveskillsinmanaging,teaching,and negotiating,andin collaboratingwithmultidisciplinaryteamsandclient/familyfocus. Experienceworkingwithpeople livingwith disabilities with complex LTSS and BH needs.Preferencegiventobi-lingual/bi-culturalapplicantsand those withlivedexperience.Insomecases, experiencemaybesubstitutedfor academictraining.
Education and RequiredCredentials/Licenses:
BA/BS in human services related field is strongly preferred.
Driving isa requirement forthisposition usinga personalvehicle.Youmustpossessandmaintain adequateinsurance aswellasmaintain a safedriving record whichissubjectto annual checks.A valid driver's licensemustbepresentedatthe timeofemployment.Incumbentsmustbe at least21yearsof age, havemaintaineda validUS driver'slicensefor atleastoneyear, andmustbeabletopass a driver's screening background check.