- Conducts Comprehensive Assessments
- Facilitates medication reconciliation with pharmacist and/or primary care team
- Engages members and care givers in active care planning with a focus on, medical, behavioral, social, member-centered care needs. Coaches and guides member/representative to meet bio/psycho/social care goals.
- Provide care coordination, which may include but is not limited to facilitating care transitions, supporting the completion of referrals, and/or providing or confirming appropriate follow-up
- May be required to meet members while they are inpatient to provide education and support about the discharge process and transition the member into care management**
- Travel throughout assigned area to engage members at their homes or other locations where the member may be located **
- Assesses the member’s knowledge of their medical, behavioral health and/or social conditions and provides education and self-management support based on the member’s needs and preferences.
- Connects members with primary care, behavioral health, flexible services, Community Partner, respite, and other community based social services as indicated and appropriate.
- In collaboration with Community Health Workers creates and maintains a comprehensive inventory of local community resources through a web-based application, improving accessibility for members and providers, and linking members with the appropriate support services.
- Participates in the integrated care team meetings and rounds as required
- Maintain accurate, timely documentation in electronic systems including health center EHRs
- Provides coverage for team members who are out of office
- Other duties as assigned
- Demonstrated success in working as part of a multi-disciplinary team including communicating and working with Providers, Nurses, Community Health Workers, and other health care teams
- Ability to flexibly utilize clinical expertise to solve complex problems
- Experience working with patients with chronic and behavioral health needs
- Must be flexible and adaptable to change
- Demonstrate the ability to work independently
- Must demonstrate excellent interpersonal communication skills
- Additional qualities that would be a good fit for our team include: Enthusiasm and passion for helping patients, genuine spirit, kind, and empathetic nature, and one who embraces a ‘go with the flow’ mentality
- Experience using appropriate technology, such as computers, for work-based communication
- Experience and proficiency with Microsoft Office and online record keeping
- Experience working with a Medicaid population is strongly preferred
- Experience working with Federally Qualified Health Centers is strongly preferred
- 2-3 years of Inpatient or Community Social Work experience providing patient-centered outreach, behavioral health services, needs assessment and support
- Licensed Clinical Social Worker (LCSW or LICSW),orLicensed Mental Health Counselor (LMHC)
- Master’s Degree in Psychology, Social Work or related field
- A valid driver’s license and provision of a working vehicle
- Experience with anti-racism activities, and/or lived experience with racism is highly preferred
To Apply: Please use link below-
** In compliance with Covid-19 Infection Control practices per Mass.gov recommendations**
Community Care Cooperative
- Total Years Experience 0-5