Schedule: Monday-Friday 40 hours
Bay Cove Human Services, Inc. a leading Massachusetts human services organization, seeks an LTSS Care Coordinator to provide Long Term Services and Support (LTSS) care planning, coordination and advocacy for MassHealth Members with complex healthcare needs who are enrolled in an Accountable Care Organization (ACO) or Managed Care Organization (MCO).
The LTSS Care Coordinator collaborates with the respective Community Partner team and the clinical staff of each Enrollee’s ACO/MCO’s plan to minimize duplicative efforts, promote integrated care, ensure quality and continuity of care, and support the values of person centered planning.
This role drives outreach and engagement, social needs assessment, LTSS care planning and care coordination, support of care transitions, health and wellness coaching, as well as community and social services connections in partnership with Enrollees and their designated care teams.
Bay Cove is looking for someone who strives to:
- Challenge thinking.
- Be different.
- Lead change.
We are looking for people who are inspired and inspiring.
You will do:
- Collaborate with their respective Community Partner team and the clinical staff of each Enrollee’s ACO/MCO’s plan to minimize duplicative efforts, promote integrated care, ensure quality and continuity of care, and support the values of person centered planning.
- Assesses Enrollee for social services.
- Informs Enrollee about options for specific LTSS services, programs, and providers that best meet identified needs.
- Identifies community and social services that will support the health and well being of the Enrollee.
- Develops LTSS Care Plan in partnership with Enrollee and their designated Care Team.
- Supports Enrollee’s LTSS care need decisions and LTSS integration in the Care Plan.
- Provides monitoring and implementation of Care Plan to ensure LTSS are relevant and appropriate.
- Promotes and facilitates the integration of the Enrollee’s LTSS care across physical, behavioral and LTSS areas as well as social services and Flexible Services as applicable.
- Assesses Enrollee for Flexible Services – if identified ,request approval from ACO.
- Educate and support members’ families and friends regarding members’ needs and preferences as they relate to overall health and well-being.
- Demonstrated knowledge of clinical and Long Term Services and Supports resources, values, principles, and techniques.
- Demonstrated experience with case management and creating care plans Computer Skills- strong knowledge of Microsoft Office.
- Problem solving skills- demonstrated experience in evaluating all aspects of a problem or opportunity and make or facilitate appropriate and timely decisions.
- Effective communication skills- ability to facilitate, exceptional customer service; organizational skills.
- Education- Bachelor’s in Human Services or a related field High degree of social facility in obtaining cooperation and support from a broad range of people.
- Ability to work collaboratively- within an organization and with leaders of external organizations.
- Driving is a requirement for this position using a personal vehicle.
- Driving License Required? Yes