Care Coordinator - RISE Program

Job Description

Job Description

Who We Are:
Since 1985, BHCHP’s mission has been to ensure unconditionally equitable and dignified access to the highest quality health care for all individuals and families experiencing homelessness in greater Boston. Over 10,000 homeless individuals are cared for by Boston Health Care for the Homeless Program each year. We are committed to ensuring that every one of these individuals has access to comprehensive health care, from preventative dental care to cancer treatment. Our clinicians, case managers, and behavioral health professionals work in more than 30 locations to serve some of our community’s most vulnerable—and most resilient—citizens.

From our earliest days as a program, we have always sought to do work that is transformational: recognizing our shared humanity; centering dignity, compassion, mutual respect and supporting the right of every individual to access the highest levels of health care and every staff member to reach their fullest potential. We continue to be committed to building bridges and breaking down barriers, including systemic racism which harms us all. We provide community-based health care services that are compassionate, dignified, and culturally appropriate, incorporating social determinants of health, with the goal of breaking down the physical and systemic barriers that our patients face.

Job Summary:
Union: Yes
Union Name: 1199SEIU
Patient Facing: Yes

The Care Coordinator will be an integral part of a multidisciplinary team within our RISE (Reentry Initiatives for Support and Empowerment) program working with homeless, incarcerated individuals in Suffolk County. BHCHP has partnered with the Suffolk County Sheriff’s Department (SCSD) at two county jails to outreach to this population. This program aims to engage this population prior to release, to connect with external Medication for Opioid Use Disorder (MOUD) partners to improve transitions of care for these individuals upon release, and ultimately to improve outcomes related to drug use in this population who are at a particularly high-risk of fatal overdose upon release. The Care Coordinator will join an interdisciplinary team of doctors, nurses, a clinic/project director, therapist, care coordinators, recovery coach and others working together to support incarcerated individuals with a diagnosis of opioid use disorder, those at high risk of fatal overdose prior to release, and those with chronic health conditions on the day of release, and in the post-release period to provide the following:

• Pre-release support including Critical Time Intervention, case management, behavioral health services, psychiatry, recovery support groups, legal case management, MOUD evaluations, HIV and HCV screening and referrals, and referrals to recovery coaching. Services are provided directly in-person at the jail when permitted, or by telehealth encounters.
• Support on day of release from jail including in person visits to the jail or courthouse, transportation support, care coordination, accompanying individuals to medical appointments and to obtain prescriptions, naloxone provision and naloxone training for overdose reversal.
• Post-release support including a continuation of pre-release supports, as well as support with direct MOUD provision, psychiatric treatment/medication bridging, individual therapy, and Hepatitis C (HCV) treatment.

BHCHP utilizes a community-based overdose prevention model to recovery and the care coordinator will be working with individuals at all stages of recovery, including people who are actively using drugs. This position offers a tremendous opportunity to work at the intersections of the opioid epidemic, incarceration, and homelessness, to address the root causes of illness in a collaborative team-based community health center context. Applicants proficient in both English and Spanish are encouraged to apply.

This position is funded until the end of February 2027 with the possibility for renewal.  If this funding is not renewed, this position will end February 28th , 2027 .

Responsibilities:

• Meet with patients in jails to assess patients’ financial, housing, legal, addiction treatment, and other social service needs in the pre-release period. Develop comprehensive patient centered care coordination plans to address these needs and provide support and follow up in the post-release period; work with program participants to ensure they are effectively bridged to community-based OUD treatment post-release, including mitigating lapses in care associated with waiting lists and other barriers.
• Obtain program participants’ consent to communicate with community-based OUD treatment providers, in accordance with HIPAA and 42 CFR; obtain informed consent to participate in the program evaluation and assist with data collection at baseline and 6-month time points; in partnership with SCSD staff, provide care coordination services to enroll or facilitate re-enrollment in insurance coverage for all program participants prior to or immediately after their scheduled release from SCSD, to ensure there are no gaps in coverage that would otherwise preclude individuals from continuing MOUD post-release.
• Provide care coordination to support reentry, identify community resources, and connect participants to medical and social services post-release (such as transportation, primary care, naloxone, and housing-related resources); screen individuals for interest in HCV treatment and actively supporting their connection to BHCHP’s HCV treatment team (or other HCV treatment programs in the community). 
• Ensure program participants have scheduled appointments, if clinically indicated, with the following providers upon release: primary care, behavioral health including psychiatry, specialty care including HCV services, and support attendance at these appointments by facilitating transportation and/or accompanying participants; document all encounters with patients in BHCHP’s electronic medical record (EMR), maintain accurate and up to date (non-clinical) records and standardized data on all patients.
• Communicate regularly with BHCHP RISE team members regarding the status and needs of the patients releasing from SCSD using a variety of HIPAA compliant communication mechanisms including email, Tiger Text, phone, and BHCHP’s EMR; serve as a liaison between the recovery community, the addiction treatment system, the medical treatment system, and the patient’s community, family, and social context to facilitate connections across systems of care.
• Co-facilitate groups at the county jails focused on care coordination, overdose prevention, and recovery-related topics for individuals while they are incarcerated; clearly and effectively facilitate communication between the patient, physician, therapist, psychiatrist, recovery coach, and any external providers maintaining appropriate confidentiality procedures and professional boundaries.
• Systematically review the RISE team panel of patients each week, focusing on new patients and patients who are having difficulties, and upcoming releases.
• Obtain clearance to enter Suffolk County Sheriff's Department correctional facilities as a contractor within one year of hire.

Qualifications:

• Knowledge of healthy and appropriate boundaries when working with vulnerable populations; an understanding of the criminal justice system and how it is rooted in racism and oppression.
• Demonstrated interest and experience in working with vulnerable populations, including those with active substance use disorder, histories of incarceration, and/or homelessness.
• Knowledge and understanding of strategies for opioid overdose prevention and response, or willingness to be trained to become expert in these topics; comfort with multiple pathways to recovery from SUD and willingness to embrace a patient-centered approach that recognizes an individual’s preferences and autonomy.
• Comfort in working in medical, criminal justice, and social service settings; ability to work independently as well as part of a multidisciplinary team.
• Computer proficiency, effective use of the Internet and Microsoft Office programs such as Word and Outlook, Microsoft Excel, PowerPoint, and familiarity with RedCap.
• Strong advocacy skills along with knowledge of community-based services, resources, and local recovery community; ability to provide and receive accurate feedback without judgment or discomfort. 
• Flexibility to adapt to unforeseen needs or circumstances; excels at problem solving and multi-tasking and is organized, efficient and goal directed.
• Ability to handle confidential information; commitment to equitable and culturally appropriate care for a wide range of diverse populations, including (but not limited to) communities of color, LGBTQ communities, non-English speaking populations, people with histories of incarceration, people with substance use disorders and behavioral health challenges, and people experiencing homelessness.

Compensation and Benefits:

• The compensation increases based on years of experience and ranges from $22.25 - $35.60 per hour.
• 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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