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"Here For You" Care Coordinator

Universal Health Services

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Universal Health Services
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Job Details

"Here For You" Care Coordinator

Job Code:  218832
Facility: Arbour Counseling
Location: ALLSTON, MA US Northeast
Region: Northeast
Travel Involved: 0-10%
Job Type: Full Time
Job Level: 
Minimum Education Required: Master's Degree 
Category: Allied Health
FTE: 1
Position Summary:
The Agency-based Care Coordinator is the single point of contact for the integrated, seamless and person-centered service in support of Here-for-YouSM Enrollees. The Care Coordinator, under the direction of the Agency-based independently licensed supervisor, implements and monitors member adherence and response to the Care Coordination Plan (CCP). Responsibilities: •Assume responsibility for a mixed acuity case load; •Collaborate with Beacon Here-For-You Clinician and NHP Care Manager (RN), as indicated; •Conduct outreach and provide information about the Here-for-You program and benefit; •Facilitate the scheduling of and conduct the assessment, face-to-face whenever possible and clinically appropriate; •Identify need for interpreter service, cultural considerations, preferences, and accommodations; •Facilitate consents, gathering of clinical information (including all existing medical, behavioral health and treatment plans) and discussion with enrollee’s BH and medical providers, to draft the initial Care Coordination Plan (CCP); •Utilize person-centered framework to identify the enrollee’s and/or caregivers goals, preferences, and desired level of involvement; •Develop and maintain crisis plans; •Coordinate access to services and fulfillment of integrated health needs including medical appointments as directed by the CCP; •Continuously identify and resolve barriers to meeting goals and complying with the CCP; •Facilitate enrollee referrals to resources and an ongoing follow-up process to determine whether an enrollee acted upon referrals; •Develop a schedule for follow-up and communication with the enrollee; •Develop and communicate the individual’s self-management plan; •Assess progress against the CCP and goals, and modify as needed; •Reassess and update the CCP at intervals as determined by risk stratification, •Ensure that all participating providers and supports receive the CCP as it is updated, including NHP/Beacon staff; •Secure outpatient appointments for the member and facilitation of home and community based services; •Assist member in navigating the network of community based services and information; •Support safe transitions in care for members moving between settings; •Provide temporary assistance with transportation to needed medical/BH appointments when needed while transitioning to community-based transportation, (e.g., assisting enrollee with the PT1 form). •Facilitate communication between the member or designated representative and member’s healthcare providers; •Attend integrated rounds meeting as scheduled or as requested; •Participate in meetings with HERE-FORYOU clinician or Provider Oversight Clinical Liaison as scheduled or requested; •Participate in weekly supervision with Agency-based independently licensed supervisor; •Participate in all trainings conducted by Beacon or NHP; •Provide self-management, CCP and other materials in preferred language and formats when needed; •Evaluate need for med reconciliation; •Ensure member screening of medical conditions, identification of medical PCP, and connection to medical provider(s) as needed.
Education: College degree in health related field, BSW, MSW, or 5 years’ experience in community-based behavioral health support program. Candidate may be a licensed clinician who does not have the credentials to practice independently (e.g., LPN, LCSW, BSW, or degree in a related health care field). Candidate must demonstrate good boundaries regarding confidentiality and personal relationships and have the ability to evaluate what is needed by each individual and adjust approach accordingly. The candidate must have in-depth knowledge of local resources and experience with accessing resources and navigating mental health and/or substance abuse treatment systems. The candidate will demonstrate excellent communication, documentation, time management and organizational skills. The candidate is able to work some flexible hours to accomplish outreach and engagement of members at times when they are reachable; this may involve some early evening hours or later work days.

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