Complex Care Coordinator (Pine Street Inn & St. Francis House)

The Complex Care Coordinator will take responsibility for coordinating ongoing care for a panel of 25 to 50 high-risk patients. They will also provide medical case management services to walk-in patients for up to 50% of their time, depending on site needs.

Responsibilities

General Work in assigned clinics (St. Francis House and Pine Street Inn) with a multidisciplinary team of providers, nurses, behavioral health clinicians, and case managers. This position will include a combination of scheduled clinic sessions to see walk-in patients and outreach sessions as needed, with prior supervisor approval, to engage referred patients in the place where they frequent, receive care, and/or reside, and to accompany patients to appointments, court, etc. Document patient encounters, as well as all outreach attempts, in the electronic health record. Collaboratively develop, and document progress towards, patient-identified goals and a plan of care for each patient. Coordinate services and assist patients with obtaining benefits, housing, housing tenancy supports, transportation, and other services that address their health-related social needs. Support patients’ access to public health supplies by regularly stocking BHCHP’s public health vending machine and helping patients register for access to the machine. Develop and maintain awareness of community resources and services available to patients. Promote appointment adherence by assisting patients with scheduling and rescheduling missed medical and behavioral appointments, including specialty care, as needed. Support referrals to SUD treatment programs as needed. Identify and develop cooperative working relationships with service providers for people experiencing homelessness, and coordinate housing supports using Homeless Management Information Systems (HMIS) when appropriate. Work with patients to complete MassHealth applications and redeterminations to avoid disruptions to coverage. Successfully complete the MassHealth Certified Application Counselor exam (CAC) within 60 days of hire and maintain active certification status. Complex Care Coordination for High-Risk Patients In addition to the services outlined above: Outreach and engagement: Make best efforts, using multiple attempts and modalities, to successfully outreach and engage newly assigned patients within 30 days of their assignment to the care management panel, or within other timeframes as determined by payor. Needs assessment: Complete intake, comprehensive needs assessment, and care plans for primary care patients referred by Accountable Care Organizations or internal care teams for high-risk care management. Update these documents at least annually or when the patient’s condition changes as required by the ACOs. Support during transitions of care: Provide intensive, timely care coordination to patients during transitions of care, including but not limited to participating, as appropriate, in discharge planning with inpatient health care providers. Follow-up after hospitalization: Follow up with patients face-to-face or by telephone following an inpatient or Emergency Department discharge to coordinate clinical and supportive services.

Documentation

Follow billing, documentation, and assessment guidelines as required by payors. Use data to evaluate outcomes and adjust interventions as needed. Participate in weekly case conference meetings to discuss mutual patients with care team members to maintain integrated care model. Participate in ongoing trainings on care management principles and practices.

Qualifications

A bachelor’s degree in a behavioral health field (e.g., social work, human services, psychology, sociology, or related field); or at least three years of relevant professional experience. Able to work with multidisciplinary team maintaining a good rapport with nursing staff, medical staff, other departments, and visitors Strong problem solving and communication skills (written and oral) Excellent customer service skills and the ability to communicate professionally with employees and patients, both on the phone and in person Efficient, organized, detail-oriented, and able to complete tasks in a time-sensitive manner Self-directed with the ability to work independently in multiple settings Flexible and adaptable to different health care delivery models Knowledge of the network of services available to homeless persons, and experience working with homeless persons preferred Prior case management experience preferred Computer skills: proficiency with Microsoft Office, including Microsoft Excel, and entering narrative and other data into electronic medical records and other internet-based products Spanish or Haitian Creole language skills strongly preferred Willingness to travel to outreach/various sites Valid driver’s license and car required or strongly recommended to travel to multiple sites Compensation and Benefits: The compensation increases based on years of experience and ranges from $22.25 - $35.60 hourly. BHCHP full time employees are eligible for our competitive time off program, health, dental and vision insurance, 403B retirement savings plan, pre-tax MBTA pass program with 40% discount, additional compensation for demonstrated bilingual proficiency and more. Benefits are prorated for part-time employees Does this amazing opportunity interest you? Then we'd love to hear from you. As an equal opportunity employer, Boston Health Care for the Homeless Program is committed to providing employment opportunities to all qualified individuals and does not discriminate on the basis of race, color, ethnicity, religion, sex, gender, gender identity and expression, sexual orientation, national origin, disability, age, marital status, veteran status, pregnancy, parental status, genetic information or characteristics, or any other basis prohibited by applicable law. Covid-19 Vaccination: Proof of Covid-19 vaccination(s) is optional for employment. Candidates who are offered employment will be given details about how to demonstrate receipt of vaccination if they choose to. Please Note: Employment at Boston Health Care for the Homeless is at-will. Boston Health Care for the Homeless does not sponsor work authorization visas.

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