Licensed Care Manager, Complex Discharge Planning

Location: Boston (Hybrid)

Organization Summary:

Community Care Cooperative (C3) is a 501(c)(3) non-profit, Accountable Care Organization (ACO) governed by Federally Quality Health Centers (FQHCs). Our mission is to leverage the collective strengths of FQHCs to improve the health and wellness of the people we serve. We are a fast-growing organization founded in 2016 with 9 health centers and now serving hundreds of thousands of

beneficiaries who receive primary care at health centers and independent practices across Massachusetts. We are an innovative organization developing new partnerships and programs to improve the health of members and communities, and to strengthen our health center partners.

Job Summary:

As an integral member of the care management team, the Licensed Care Manager (CM) will have the opportunity to have a profound impact on the lives of people living with complex and/or chronic conditions, many of whom also face multiple barriers in their lives, which make it difficult for them to achieve the self-care required to improve their health and well-being. This position is currently hybrid, but requires flexibility, and may vary from day-to-day to meet members where they are. Outreach methods are based on the needs of the organization and the member, and may include telephonic, or in-person engagements in a variety of potential settings, such as the health center/practice, community, home, or an inpatient facility. 

Responsibilities:

• Conducts Comprehensive Clinical Assessments for both adult and pediatric members
• Ensure that medication reconciliation is completed, as indicated. BH Care Managers will refer all medication reconciliations to a Clinical Pharmacist
• Actively engages members and caregivers in collaborative care planning, focusing on medical, behavioral, social, and member-centered needs. Coaches and guides member/representative to meet bio/psycho/social goals
• Manages complex discharge planning needs for members (adult and pediatric) experiencing extended inpatient stays or frequent ED visits, and actively participates in regular meetings with hospital staff, providers, care team, and community services
• Partners with MassHealth and other state agency contacts to facilitate care transitions to the safest level of care
• May be required to meet members while they are inpatient to provide education and support about the discharge process and transition members into care management
• Assesses the member’s knowledge of their medical, behavioral health and/or social conditions and provides education and self-management support plans based on the member’s needs and preferences
• Connects members with primary care, behavioral health, social services, Community Partner, respite, and other community-based services, as indicated and appropriate
• Participates in the integrated care team meetings and clinical rounds, as required
• Maintain accurate, timely documentation in electronic systems, including health center/practice EHRs
• Provides coverage for team members who are out of office
• Other duties as assigned 

Desired Skills:

• Demonstrated success in working as part of a multi-disciplinary team including communicating and working with Providers, Pharmacists, Nurses, Community Health Workers, and other health care teams
• Demonstrated success in identifying and supporting members with high utilization patterns, complex needs, and social risk factors to reduce avoidable admissions/readmissions and improve continuity of care
• Must demonstrate excellent interpersonal communication skills
• Ability to flexibly utilize clinical expertise to solve complex problems
• Experience working with patients with chronic medical and behavioral health needs
• Must be flexible and adaptable to change
• Demonstrate the ability to work independently
• Bi/multi-lingual preferred
• Experience using appropriate technology, such as computers, for work-based communication
• Experience and proficiency with Microsoft Office and online record keeping 
• Experience with anti-racism activities, and/or lived experience with racism is highly preferred

Qualifications:

• Experience within the ACO’s member population preferred, including Medicare/Medicaid member populations
• Experience working with Federally Qualified Health Centers/ Primary Care Provider practices is strongly preferred
• Licensed Clinical Social Worker (LCSW or LICSW), or Licensed Mental Health Counselor (LMHC) or LSW with 3-5 years of Care Management/ Complex Discharge Planning Experience
• 2-5 years of inpatient or community Social Work experience providing patient-centered outreach, behavioral health services, needs assessment, and support
• A valid driver's license and provision of a working vehicle

** In compliance with Infection Control practices per Mass.gov recommendations, we require all employees to be vaccinated consistent with applicable law. **