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CSS Care Coordinator

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Published
December 21, 2020
Location
Stoughton, MA
Category
CSS  
Job Type

Description

Responsibilities:

The Community Care Coordinator (CCC) works with individuals and caregivers within the Cambridge Health Alliance (CHA) primary care settings and is an integral member of the Complex Care Management team at one Primary Care Region (including one or more Sites). The Community Care Coordinator works closely with site-based Complex Care Managers (CCM), patients, and the practice’s primary care teams to effectively manage the practice’s Highest Risk patients. The Community Care Coordinator provides care management and system navigation supports to patients with a diagnosis of substance use disorder and/or co-occurring mental health disorders. The Community Care Coordinator also works closely with CHA’s Inpatient/ Emergency Department teams to coordinate transition plans for hospitalized patients receiving primary care in their region. Additionally, the Community Care Coordinator assesses patients post discharge to identify gaps in services, making referrals as needed and serving as a bridge between the patient, the primary care practice, acute care and their recovery networks, streamlining patient referrals to community-based resources.
The Community Care Coordinator performs the following duties:
•Provides Transition of Care (TOC) support for CHA primary patients both at CHA and at outside facilities. Specific duties will be focused on early identification of barriers impeding optimal transition to home/community, optimization of appropriate services and support, including medication review and ensuring connection to Primary Care Providers (PCP).
•Evaluates patients for mental health and substance use problems and psychosocial factors impacting care and coordinates referrals for patients accordingly.
•Collaborates with mental health providers to support medical management for patients with co-morbid mental health and substance abuse disorders.
•Facilitates access to navigate federal, state and community entitlement programs, insurance benefits, and Department of Public Health and Department of Mental Health services. Supports patients/clients/with applications and assists with follow-up as appropriate.
•Provides follow up contact with patients after medical appointments to insure that patients understand and accept the care plan and develops strategies to support implementation of the care plan.

Qualifications:

•Bachelor's degree in Psychology, Social Work, Human Services or a related field and at least two years of experience in the human services field.
•Community Health Worker Certification or ability to obtain certification within 1 year post hire.
•Experience in individual needs assessment and care planning for substance use and mental health.
•Knowledge of current practice standards in addiction treatment system preferred.
•Demonstrated cultural competency and fluency in Spanish or Portuguese or Haitian Creole preferred.
•Demonstrated professional writing, interpersonal, communication, oral presentation, and organizational skills.
•Proficiency in computer applications including spreadsheet preparation.

Driver's License Required?

No

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