Job Information
Center for Human Development Care Coordinator - LTSS in Pittsfield, Massachusetts
SIGN ON BONUS AVAILABLE!!!! Providing evidence-based care coordination and management, ICP care coordinators ensure that more people in our communities can benefit from all exceptional health services. JOB EXPECTATIONS - Collaborates with the Enrollee\'s care team (registered nurse, PCP, PCA, medical director, behavioral health specialists, ACO\'s, DMH, CBHI, CBHC, medical supply stores, social workers, etc.) - Encourages Enrollee to follow treatment recommendations through support, health and wellness education, and advocacy. -Links enrollees with resources and encourage them to use them to their advantage. - Utilizes recovery strategies such as Motivational Interviewing, Harm Reduction and Strength Based approaches to support enrollees in attaining stated goals. - Conducts visits in the home or in other locations in the community to provide guidance, support, education, and coaching. Follow-up by telephone as necessary. - Accompany/transport enrollees to medical/mental/behavioral health appointments as requested; facilitates effective navigation of the health care system - LTSS Care Coordinators work with children ages 3 years old all the way up to adults who are 65 years old. - Assists Enrollees in having an annual primary care visit. - Completes Enrollee driven assessments, health screeners, Releases of Information and care plans annually. Complete daily activity notes in our electronic medical record. - Ensures electronic medical record is up to date. - Completes a face-to-face visit every 90 days. - Ensures that Enrollee has an annual oral health evaluation. - Participates in multi-disciplinary care team meetings. - Ensures monthly contact with all enrollee\'s on caseload. - Attends care team meetings, supervisions, Team meetings, MVP meetings, staff meetings, trainings, and various other meetings in regards to health care management. - Manage a large caseload - Maintain the ability to adapt and remain flexible with changing MassHealth, EOHHS, and CMS requirements and ongoing clarifications of the Community Partner Program - Transports enrollees to connect with local community resources and to attend healthcare appointments. QUALIFICATIONS - Must have a vehicle available for work purposes that is registered and insured - Must have a valid and active driver\'s license - Bilingual and Bachelor Degree level applicants are encouraged to apply PREFERRED - CPR Certificate - First Aid Certificate - Medication Admin