Description

Upham’s Corner Health Center is non-profit organization committed to providing high quality, low cost, culturally sensitive, and community-based health and social services to the residents of North Dorchester and adjacent neighborhoods. Our goal as a health center is to provide each patient with primary care in comfort and convenience. The provider and care team work together to provide ongoing care and coordinate specialty services and inpatient care as required.

Riverside Community Partners program is a Behavioral Health Community Partners (BHCP) program made up of Riverside Community Care as lead contractor to MassHealth and six affiliated partner organizations, one of which is Upham’s Corner Health Center. The partnership supports functions focused on Care Management and Care Coordination to assist members with high BH needs (SMI and/or SUD) in better navigating the complex BH system. The program involves outreach and engagement, comprehensive assessment and person-centered treatment planning, care coordination and care management, care transitions, medication reconciliation, health and wellness coaching, and connection to community, social, and flexible services.

Primary Function:

The Care Coordinator will serve as a member of UCHC’s Behavioral Health Community Partners (BHCP) team, providing person-centered and recovery oriented care management and coordination to assigned Enrollees, including but not limited to: outreach and engagement, assisting Enrollees to identify goals and to develop an individual care plan, completing comprehensive Assessments, facilitating Care Teams, coordinating communication among Enrollees, their healthcare and other providers, involved state agencies and others, and supporting Enrollees to access and utilize resources to improve and maintain their health and quality of life. 

Duties & Responsibilities:
General Responsibilities
• Complies with all mandated reporting requirements and regulations (i.e. DCF, DMH, DPPC, Elder Protective Services).
• Reads and follows procedures as detailed in Riverside and UCHC program policies and procedures.
• Attends and utilizes supervision meetings. Brings issues of concern and/or importance to supervisor for consultation.
• Maintains a professional work environment with attention to persons served and staff health and safety by maintaining protocols, alerting management to unsafe conditions, etc.
• Attends all required trainings and administrative meetings.
• Handles other duties as assigned.

Direct Service Provision
• Conducts outreach and engagement activities to encourage CP enrollment, including ensuring mechanisms for communication among Enrollees and others involved in Enrollees’ care in all aspects of assessment and care planning and coordination activities.
• Functions as the primary care coordinator for assigned Enrollees including conducting face-to-face, telephonic and electronic outreach with Enrollees and maintaining ongoing communication.
• Completes comprehensive Assessments, Person-Centered Care Plans and updates as required by program protocols and policies in conjunction with Enrollees, their Care Teams and other BHCP team members.
• Facilitates communication and collaboration among all Enrollees’ health and behavioral health care providers, family and community resources, especially during times of transitions between levels of care or when changes to the Person-Centered Care Plan are made, supporting Enrollees to actively engage in medical, behavioral health, social services, wellness activities and other resources to promote their health and well-being.
• Coordinates with the Nurse Care Manager/Team Leader and others to ensure all aspects of the BHCP services are approved, provided and reviewed as needed and in accordance with program protocols and policies.
• Organizes and facilitates Care Team meetings.
• Maintains regular contact with Enrollees (and their families when appropriate).
• Assists Enrollees with navigating through all systems of care, provides referrals to appropriate services and supports, coaches and assists Enrollee to attain health and wellness goals.
• Other duties as appropriate to the Care Coordinator role and as may be assigned.

Administrative
• Complete all clinical documentation, including Assessments, Care Plans, progress notes, updates, incident reports, forms, etc. in a complete and timely manner and in compliance with organization and relevant state protocols.
• Completes all required administrative documentation, including but not limited to reports, statistics, timesheets, etc. in a complete, accurate and timely manner in compliance with organization and relevant state or payer requirements.
• Assumes additional responsibility consistent with program needs and staff role, as defined in consultation with the Nurse Care Manager/Team Leader.

Qualifications

Minimum Basic Knowledge:
• Bachelor’s degree
• Physical and cognitive abilities and knowledge base to:
- Respond and work with consumers, staff, managers and external parties in a professional, respectful, and sensitive manner.
- Safely perform job functions with or without the aid of mechanical devices.
- Comprehend and carry out policies and procedures using specific instructions and accepted practices.
- Assess complex situations, collaborate and integrate different viewpoints and use good judgment when dealing with others.
- Clearly communicate verbally and in writing in language that can be readily understood by the majority of the program’s clients, staff and funders. 
- Effectively perform job responsibilities in a high paced environment. 

Experience & Qualifications:
• Two years of experience working with people with behavioral health disorders required; experience working with substance use disorders preferred.
• Must embrace person-centered planning philosophy.
• Ability to use a computer for word processing, EHR and email/Outlook Calendar, and the Internet for resource searches and assisting clients with online surveys and using online decision-making tools required.
• Regular access to reliable transportation is required in order to attend required trainings, meetings and/or fulfill other responsibilities of this role.
• 2nd language capacity for Spanish OR Cape Verdean Creole OR Portuguese in addition to English 

Independent Action:
Plan own work and priorities, referring complex or unusual problems to supervisor.

Supervisory Responsibility:
No direct reports

Define Access Level to PHI:
Level 4 [Authorized to access full health information. UCHC position and job responsibilities involve the provision of patient care and working as a clinical team member. Staff in this category level, although allowed full access, should only access the necessary information for reach respective treatment encounter/circumstance].