Position Title: Clinical Care Coordinator

Department: Human Services Department

Exemption: Non-Exempt

Supervisor: Clinical Director

Job Summary:

As part of the Veteran 360 Behavioral Health Programs, provide community-based case management services for Veterans experiencing homelessness with serious mental illness, substance use disorders, and/or complex medical illnesses. Link Veterans to needed care including mental health, substance use, and primary care as well as services that address social determinants of health. This role is a part of a MassHealth initiative that provides qualified MassHealth enrollees with a service benefit called Behavioral Health Community Partners (BH CP). This initiative is led by the Boston Health Care for the Homeless Program, who has partnered with community-based providers to form the Social Determinants of Health BH CP Consortium to serve eligible MassHealth enrollees in the greater Boston area.

Job Responsibilities:

• Work as part of an interdisciplinary BH CP team and coordinate the care for enrollees. Work closely with nurse care managers to engage enrollees regularly (several times a month) in face to face interactions to assist them in connecting to vital services and progress towards the goals outlined in their Person-Centered Care Plan.
• Work with the nurse care managers to conduct timely Comprehensive Assessments.
• Maintain weekly communication with the BH CP team via data sharing platform to improve coordination of information sharing/collaboration between enrollee and BH CP teams.
• Ensure timely documentation into data platform regarding enrollee progress on Care Plan goals, all enrollee encounters and care coordination notes.
• Assist nurse care managers and BH CP teams with arranging enrollee appointments for services needed and other related assessments and accompany enrollees to appointments as needed.
• Triage and troubleshoot care need issues for enrollees and work with nurse care managers to address needs.
• Participate in team case conferences and advocates for enrollees’ needs.
• Participate in BH CP training and learning collaborative.
• Remind enrollees about appointments, filling prescriptions, etc.
• Work with BH CP team on the development and implementation of Patient Centered Care Plan.
• Request and send medical records for care coordination purposes to providers, Accountable Care Organization and Managed Care Organizations as needed.
• Collaboration with both community and medical partners to coordinate care services to meet participant need.
• Attend staff trainings and meetings as required.
• Provide referrals or assistance linking to community-based services and benefits
• Perform other duties as assigned or as they may arise.