Care Coordinator

Provider centered. Patient focused. Built for what healthcare should be. The Care Coordinator (CC) is a trusted member of the Care Management team who facilitates the care of members faced with behavioral health (BH), medical, and social determinants of health (SDOH) challenges, to promote adherence to key components of their health care. The CC engages patients, creates a trusting relationship, and provides care coordination to patients with health needs. They will work with the patient to set health goals and closely communicate with members of the patient’s care team. The CC provides support and assists members in understanding the implications and complexities of their current situation and/or overall personal care. The CC plays a critical role in improving member quality of life by helping individuals remain safe, stable, connected to treatment, and successfully supported in the community — ultimately optimizing overall health outcomes. Key Responsibilities Provides face-to-face or telephonic care coordination to patients with determinant social challenges who have high rates of Emergency Department and/or Inpatient utilization and/or severe psychosocial vulnerability Provides care coordination services to patients in the community, homes and health care settings that patients access Conducts screenings and assessments with patients and performs interventions through the development of a care management treatment plan specific to each member with high level acuity needs Addresses barriers to follow through on health care including, but not limited to: homelessness/housing instability, financial resources, transportation, etc. and places referrals to community-based resources as necessary Places external community-based resources to assist patients in accessing quality and cost-effective care (e.g., outpatient therapy, medication management, day treatment, Child Behavioral Health Initiative (CBHI) Services, etc.) Reviews benefits options, research community resources, and enables patients to be active participants in their own healthcare Coordinates care with internal and external resources to meet identified needs of patient’s care plan and collaborates with providers Monitors and evaluates effectiveness of care plan and modifies plan as needed Ensures patients are engaging with their PCP to complete their care management treatment plan or preventive care services Acts as a liaison and advocate between patient, family, physician, and facilities/agencies Interacts with patients, family, physician(s), and other resources to determine appropriate action needed to address needs Provides concise and thorough documentation Demonstrates cultural sensitivity and respect for patients Education Bachelor's degree in a health care related field preferred. Years Of Experience Two to five years of experience in social services care management and/or social services care setting focusing on BH/Social Determinants of Health among adult individuals, children, and families preferred. Specialized Knowledge Experience working with individuals with serious mental illness, substance use disorders, or complex behavioral health needs Knowledge of MassHealth, behavioral health systems, and community resources. Strong communication, organizational, and care coordination skills Ability to build rapport with diverse populations using a trauma-informed and culturally responsive approach Proficiency with electronic health records and documentation systems. Strong knowledge in Microsoft Office applications Experience working with the needs of vulnerable populations who have chronic or complex bio-psychosocial needs Experience working with disadvantaged populations, strongly preferred Experience in a managed care environment and case management experience, preferred Must be able to effectively communicate, present and explain complex material with patients, family members, case managers, treating physicians and community organizations Must possess the interpersonal skills to engage individuals and families in helping relationships Must be able to cope with the pressure of time limitations while respecting the needs of the patient and the requirements of the organization/department Ability to act in solving problems while exhibiting judgment and a realistic understanding of issues; able to use reason, even when dealing with emotional topics Ability to remain open-minded and change opinions based on information, perform a wide variety of tasks, and change focus quickly as demands change, and manage transitions effectively from task to task Ability to travel within the community, including valid driver’s license and auto liability insurance coverage, according to company policy Must possess a strong belief in an organizational culture that encourages valuing and best service excellence practices demonstrated through personal behavior and work ethic Ability to work in several databases and to comply with established documentation requirements Exceptional organizational skills; ability to multi-task and work independently and part of a team Demonstrate ability to prioritize, multitask, and work in a rapidly changing environment with multiple demands Possesses knowledge and expertise of the healthcare system and resources available in the area in which CM is providing care coordination/care management services Demonstrates knowledge and understanding of the impact of the community and culture on health, illness, health practices, health beliefs, access to care and participation in treatment and services Working knowledge of community based and government services and resources need to assist patients in accessing services and addressing potential Social Determinants of Health Why You Will Love Working Here We take care of our team so they can take care of patients. Benefits include: Medical, dental, and vision coverage Company funded HSA + exclusive healthcare discounts 401(k) with company match Company paid life insurance Flexible time off + Vacation Exchange Program Medical Assistant Certification Reimbursement What We Value Trust. Ownership (Together). Compassion. Relentless Progress . These values shape how we show up for patients — and for each other. If you’re ready to grow, make an impact, and be part of a connected care team, we’d love to connect. Bookmark Medical is committed to a workplace that supports and sustains inclusion and belonging. Bookmark Medical does not discriminate in employment opportunities or practices on the basis of race, color, religion, gender, national origin, age, physical or mental disability, pregnancy, childbirth or related medical conditions, military service obligations, citizenship, sexual orientation, genetic information, or any other characteristic protected by applicable local, state, or federal law. #J-18808-Ljbffr Bookmark Medical