Clinical Care Partner- Health Home
Company: Bay Cove Human Services, Inc.
Location: Boston
Posted on: May 28, 2023
Job Description:
$4,000 BONUS- $2,000 after 3 months, $2,000 after 6 months
Schedule: Mon-Fri 9am-5pm, 8am-4pm, flexible hours
Mission Statement: Bay Cove Human Services partners with people to
overcome challenges and realize personal potential. Job Summary :
The Clinical Care Partner acts as a liaison between the health
insurer, Commonwealth Care Alliance, community providers, and Bay
Cove staff. The Clinical Care Partner c oordinates all aspects of
medical and psychiatric care for those receiving services from Bay
Cove Human Services that are enrolled in CCA's One Care Plan;
coordinates and facilitates Interdisciplinary Care Team (ICT)
meetings and other activities of the ICT; participates in the
Initial Health Needs Assessments of each member; facilitates the
development of an Integrated Care Plan (ICP) for each member;
educates people about CCA One Care program benefits, services and
supports; provides assessments as needed; coaches self-management
skills as needed; and facilitates access to community services. The
Clinical Care Partner collaborates with CCAs Clinical Team and Bay
Cove in order to maximize the goal of medical and psychiatric care
integration for clients. As the driver of the Interdisciplinary
Care Team (ICT), the Clinical Care Partner provides the highest
quality and continuity of care for members. This is an exempt
position. Essential Functions of Position:
The essential job duties/responsibilities of the position include
but are not limited to the information listed below: The Clinical
Care Partner partners with both the Clinical team of CCA and
contracted Partners in the provision of intensive case management
and coordination for clients with complex needs.
- Conducts assessments of clinical health risk and needs, as well
as of clients' strengths, preferences and preferred family and
community supports and develops member directed care plan which is
then documented into CCA's care management platforms (Altruista's
Guiding care and eCW);
- Directs the planning, coordination, implementation, monitoring
and review of the member's care plans, including health care
strategies;
- Offers the services of an LTSS Coordinator, and arranges for
LTSS Coordinator participation in the assessment, care planning and
ongoing Interdisciplinary Care Team (ICT) activities. Facilitates
the effective functioning of the Interdisciplinary Care Team (ICT),
including coordinating meetings, facilitating communication and
documentation;
- Collaborate closely with PCP and other Providers including, but
not limited to community resources, and ensure appropriate
referrals based on level of care needed to optimize outcomes and
minimize risk;
- Reviews and monitors ICPs and accompanying strategies developed
by the team.
- Effectively communicates any proposed changes in services,
hospitalizations, medication changes, transitions of care, crisis
intervention, and changes in patient level to all ICT members.
- Obtains required prior authorization from CCA;
- Provides coaching and support to clients as needed.
- Educates members about program benefits, services and community
supports and services.
- Follows up within 48 hours of a member's admission to an acute
medical or psychiatric hospital, and coordinates with member and
hospital staff to facilitate hospital discharges.
- Supports safe transitions for members moving between care
settings, including but not limited to hospital to home, hospital
to rehabilitation settings, rehabilitation settings to home,
hospital to shelters, substance abuse treatment programs to
community residence programs;
- Conducts medication review and reconciliation.
- Ensures timely information exchange, coordination and
integration of care;
- Maintains frequent member contact, as indicated. Requirements
for the position:
- Master of Social Work, required
- License, preferred (LICSW, LCSW)
- Experience working with people with psychiatric disability,
co-occurring disorders and complex medical needs preferred.
- Minimum of 2 years clinical and case management experienced
preferred.
- Effective skills in managing, teaching, negotiating, and
collaborating with multidisciplinary teams and member/family
focus.
- Strong time management skills.
- Excellent written and oral communication skills.
- Familiarity with EMR and electronic data collection systems
such as eCW and Altruista's Guiding Care.
- Strong organizational skills.
- Knowledge of trauma-informed and culturally competent
services
- Sensitivity to the cultural, religious, ethnic, disability and
gender issues
- Skills and competence to establish supportive trusting
relationships with members
- Knowledge of empowerment and self-advocacy techniques
- Knowledge of available community health and mental health
services and resources
- Knowledge of formal and informal assessment practices
- Ability to triage/balance competing priorities
- Ability to make independent judgments and decisions
- Ability to work in a professional and confidential
capacity
- Knowledge of personal computer applications and equipment
- A COVID-19 vaccination is a requirement of the position. One
COVID-19 shot is acceptable, contingent on the individual receiving
the second shot within the allotted time frame. Personal
Characteristics:
- Ability to work collaboratively as a member of
multidisciplinary and cross-functional teams.
- Ability to function as an effective change agent.
- Ability to negotiate and resolve differences.
- Ability to function under pressure in a fast paced human
service environment.
- Ability to be flexible, open and responsive to ongoing industry
changes.
- Ability to articulate and communicate Bay Cove's mission and
strategic direction in a consistent and enthusiastic manner.
- Ability to effectively represent the Agency in a variety of
circumstances and forums.
- Ability to identify opportunities and obstacles and develop
effective, creative solutions to pursue opportunities. Physical
Requirements
- Ability to lift up to 50 pounds, to stoop, kneel, crouch, or
crawl and to reach with hands and arms Other Qualifications:
Driving Requirements: Driving is a requirement for this position
using a personal vehicle. You must possess and maintain adequate
insurance as well as maintain a safe driving record which is
subject to annual checks. A valid driver's license must be
presented at the time of employment. Applicants must be at least 21
years of age, have maintained a valid US driver's license for at
least one year, and must be able to pass a driver's screening
background check .
Baycove1
Keywords: Bay Cove Human Services, Inc., Boston , Clinical Care Partner- Health Home, Healthcare , Boston, Massachusetts
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