Bay Cove Human Services, Inc. a leading Massachusetts human services organization, seeks a Community Health Worker who will be an integral member of Care Teams that will deliver care coordination services to MassHealth members.
In this mobile community based position, the Community Health Worker (CHW) 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.
S/he 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.
We are looking for someone who strives to:
- Challenge thinking.
- Be different.
- Lead change.
Bay Cove is looking for people who are inspired and inspiring.
What you will do:
- Outreach to and engage Enrollees of an ACO plan as referred to CP Program.
- Coordinate the completion of the Comprehensive Assessment (CA).
- 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 in collaboration with team LPHAs.
- Coordinate the development, implementation, and ongoing review of the Person Centered Treatment Plan.
- 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 all 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.
What you will do:
- High school diploma or equivalent is required.
- BA/BS in human-services related field preferred.
- Certified Community Health Worker (CHW) preferred.
- Minimum of 3 years care management experienced preferred.
- Experience working with people living with SMI and/or SUD.
- Preference given to bi-lingual/bi-cultural applicants and applicants with lived experience of psychiatric conditions and/or HIV/AIDS.
- Knowledge of person-centered, strengths-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
- Driving is a requirement for this position using a personal vehicle.
- Driving License Required? Yes
Keywords: Care Coordination, Behavioral Health, Mental Health, Substance Abuse, Addiction Services, Case Management, ACO/MCO, LTSS, Developmental Disabilities, Autism, Intellectual Disabilities, ABI, Acquired Brain Injury, Rehabilitative, Recovery, Outreach services, Human Services, Nonprofit, Advocacy.
Excellent benefits package including health and dental insurance, 403(b) retirement plan, tuition reimbursement/remission, paid vacation & holidays, sick time pay, and employee referral bonuses.
Minimum Education Required