Harbor Health Services is an innovative, growing, mission-based organization that lives, serves and collaborates with our community members to achieve our mission to help individuals reach their full potential through access to local, affordable services that promote health. Harbor provides medical, behavioral health, dental, and support services to more than 34,000 patients in Boston, the South Shore, and Cape Cod. Harbor Health also operates two Programs for All-Inclusive Care for the Elderly in Mattapan and Brockton, providing comprehensive healthcare, transportation and social services for more than 580 frail elders who continue to live with dignity and independence in the community and a Woman, Infants and Children (WIC) Nutrition Program. To help further the mission of Harbor, we are looking for a talented Client and Family Case Manager to join our team at the Elder Service Plan. 

Harbor Health offers an excellent, comprehensive benefits package including Health, Dental, Vision, Life, & Disability insurance, 403b Savings Plan, Generous Paid Time Off plus 11 additional Holidays and much more! 

The Client & Family Case Manager will be responsible for helping clients and their caregivers of the Elder Service Plan to navigate and access community services, other resources, and adopt healthy behaviors. The Client & Family Case Manager supports social workers and the care team through an integrated approach to care management and community outreach and as a priority, activity will promote, maintain, and improve the health of clients and their family. 

Responsibilities:

• Manages assigned caseload of clients. 
• Establishes trusting relationships with clients and their families, e provides general support and encouragement, social support and informal counseling and advocates for individuals and community health needs.
• Provides ongoing follow-up, basic motivational interviewing, and goal setting with clients/families. 
• Refers clients into community partner programs such as housing, food and other social determinants of health needs, and engages other members of the Interdisciplinary Care Team (IDT) when client needs arise as needed.
• Assists clients with completing applications for services including housing and food stamp program. 
• Follows-up with clients and caregivers via phone calls to ensure services meet their needs.
• Assists with facility admissions and discharges.
• Helps clients connect with transportation and provides appointment reminders in special circumstances. 
• Performs community outreach including home visits as needed. 
• Exhibits excellent working relationships with clients, caregivers and staff, effectively communicating HHSI’s mission. 
• Works closely with social workers and care team to help ensure that clients have comprehensive and coordinated care. 
• Works cooperatively with other clinical personnel assigned to the same client and actively participates in required meetings to include but not limited to: Morning/Weekly Team, Plan of Care, and Family Meetings.
• Responsible for attending monthly service plan meetings for participants in assisted living and nursing home facilities.
• Creatively sources and accesses new services and programs appropriate to the needs of the client. 
• Provides consistent communication and coordination with other members of the Care Team to evaluate client/family status, ensuring that the provided information and reports clearly describe progress. 
• Acts as a client advocate and liaison between the client/family and community service agencies.
• Records client care management information in the EMR and other software no later than 24 hours after patient contact. 
• Attends regular staff meetings, trainings and other meetings as requested.
• Reviews care plans to prepare for and participate in case discussion at Care Team meeting.

Requirements: 

• Bachelor’s degree in Social Work, Human Services or related field required
• Current BLS (Basic Life Support for Healthcare Providers) certification required. 
• 1 year of experience working with the frail elder population (paid or volunteer experience) preferred.
• 2 years of professional experience of which 1 year was in providing direct case management support.
• Basic skills in effectively using Microsoft Office applications specifically, Word, Excel and Outlook
• Experience with dementia care, substance abuse and end of life care preferred. 
• Knowledge of community resources for elder populations preferred. 
• Critical thinking skills to problem solve individually, and in a team setting.
• Ability to work independently and cooperatively as part of a multidisciplinary team.
• Ability to prioritize, organize and schedule busy workdays. 
• Intermediate Business Writing skills.
• Bilingual desired, English /Spanish, Haitian Creole, Russian, and/or Portuguese.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.