Bay Cove Human Services’ mission is to partner with people to overcome challenges and realize personal potential. Bay Cove pursues this mission by providing individualized and compassionate services to people facing the challenges associated with developmental disabilities, mental illness, substance use disorders, and homelessness at more than 175 program sites throughout Greater Boston and Southeastern Massachusetts.
Bay Cove Human Services is committed to ensuring the representation and participation of candidates from diverse backgrounds and experiences. We encourage all qualified individuals, particularly those from historically marginalized groups, to apply.
Job Summary:
The Community Health Worker I (CHW I) provides care coordination and care management for MassHealth Members with complex medical and behavioral health needs who are enrolled in an Accountable Care Organization (ACO) or Managed Care Organization (MCO) plan. The CHW I collaborates with the Community Partner team and the clinical staff of each Enrollee’s ACO/MCO’s plan to minimize duplicative efforts, promote integrated care, ensure quality and continuity of care, and support the values of person-centered planning, Community First and SAMHSA Recovery Principles. The CHW I is at the helm of organizing and coordinating resources and services in response to the Enrollee’s healthcare needs across multiple settings, and inclusive of both LTSS and SDH needs. This role drives assessment and care planning, care transitions, health and wellness coaching, as well as community and social services connections in partnership with Enrollees and their care teams.
This is a non-exempt position.
Essential Functions of the Position:
Outreach to and engage Enrollees of an ACO plan as referred to CP Program.
Coordinate the completion of the Comprehensive Assessment (CA).
Conduct initial and ongoing risk assessment; design personal crisis management plans, relapse prevention and harm reduction strategies with members who have been identified as behaviorally complex in collaboration with team LPHAs.
Coordinate the development, implementation, and ongoing review of the Person-Centered Treatment Plan (PCTP) inclusive of any LTSS and / or SDH needs or goals of the Enrollee.
Drive referrals regarding connections to any community or social services that align with the Enrollees needs and goals.
Submit CA, PCTP and all PCTP updates in accordance with the data sharing agreement CP and ACO/MCO Plan.
Collaborate closely with PCP and other providers, including but not limited to community resources, to assure appropriate referrals based on level of care needed to optimize outcomes and minimize risk.
Communicate and collaborate with ACO/MCO teams and serve as a team resource.
Collaborate with ACO Plan, PCP and other health care providers regarding changes in services, care transitions, crisis intervention while focusing on continuity and quality of client care and potential efficiencies and cost-savings.
Obtain required Prior Authorization from ACO/MCO Plan for relevant/necessary services.
Manage all care transitions through collaboration with Enrollee, community provider staff, ICT and hospital staff to ensure a safe discharge plan and a well-coordinated implementation of that plan.
Ensure completion of medication review by team RN as triggered by a care transition or by a medication change through an outpatient medical or psychiatric visit.
Perform other duties, as required.
Job Requirements:
Minimum of 3 years case management experience preferred.
Experience working with people living with SMI and/or SUD.
Preference given to bi-lingual/bi-cultural applicants and those with lived experience of psychiatric conditions. In some cases, experience may be substituted for academic training.
High school diploma or equivalent is required. BA/BS in human-services related field preferred.
Certified Community Health Worker (CHW) preferred.
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. Incumbents 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.
Bay Cove Human Services does not offer visa sponsorships at this time and will require candidates to be authorized to work in the United States.
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