Community Care Coordinator

Reports to Director of Clinical Service

General Purpose: The Community Care Coordinator (CCC) is hired by the Aging Services Access Point (ASAP) to work with individuals and caregivers within the Cambridge Health Alliance primary care settings and will serve as an integral member of the clinics’ Complex Care Management (CCM) teams. The CCC will work with individuals who meet the criteria of High Utilizer, as defined by CHA, with the goals of: decreasing ED visits and hospitalizations, increasing efficiency and streamlining care, and increasing patients’ quality of care. The CCC will accomplish these goals by assisting patients in transitioning from hospital to home, assessing patients in their homes to identify gaps in services and making referrals as needed, and serving as a bridge between the patient, the primary care practice, acute care and the community.

Essential Functions:

1. Meet with assigned patients at the hospital to assess for community-based supports and make referrals as needed. Conduct follow-up home visits and telephone calls to:

a. Offer appointment reminders and explore barriers to attendance such as transportation.

b. Ensure necessary follow-up steps have been accomplished (ie. VNA referrals, prescriptions obtained) as indicated in the discharge paperwork.

c. Make referrals to elder services or other community resources as is appropriate.

d. Communicate with care providers when relevant.

2. Refer eligible patients to Complex Care, help to identify a patient care plan, and share responsibilities with the CCM Social Worker and/or Nurse, depending upon the specific patient’s needs.

3. Outreach to MassHealth ACO patients not currently connected to CHA primary care with the goal of reconnecting them with care.

4. Participate in meetings with the CCC’s assigned CCM team at the primary care site, and attend regional care integration meetings and essential internal ASAP meetings, as determined by CHA and ASAP leadership.

5. Work with other ASAP staff to assist those high-risk patients who are not currently enrolled in other care and service programs in accessing the full range of long-term care options.

6. Perform other duties as assigned.

7. Ensure compliance with HIPAA regulations.

Qualifications/Basic Job Requirements:

· Bachelor’s degree

· Bilingual preferred

· Two years of experience in individual needs assessment and care planning, with a focus on elder care issues and resources.

· Ability to be a self-starter, work independently, and demonstrate flexibility in responding to consumer needs.

· Ability to be flexible, adapt to, and work effectively in the culture of a medical environment

· Excellent interpersonal, organizational, time management and customer service skills.

· Excellent computer skills.

· Excellent written and verbal communication skills.

· Must be willing and able to use own vehicle.

Physical Environment

· Physical surroundings are comfortable with minimal exposure to injury or hazards.

Social/Psychological Conditions

· Occasional stress due to periodic or cyclical workload pressures and deadlines. Some interruptions involved.

Physical Effort

· Frequently sits, stands, walks, bends, reaches, and stoops throughout the day

· Frequently lifts, pulls, pushes, and carries up to 20 lbs.

· Periodic eye strain and light ear strain.

Professional Standards and Conduct:

1. Attendance and Punctuality: Due to the flexibility of SCES work schedules it is imperative that staff be reliable and arrive to work on time.

2. Respect & Courtesy: Everyone deserves and should expect courteous treatment, whether in person, on the phone or in correspondence. All employees should consistently maintain a positive and congenial attitude.

3. Cultural Sensitivity: Recognize and demonstrate a commitment to cultural sensitivity.

4. Commitment: Commitment to SCES’ mission can be shown in many ways such as, assisting with special projects within the agency, participating in related efforts or professional associations, creating or furthering an initiative that reinforces the mission.

Disclaimer:

The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and/or skills required of all personnel so classified.

Job Type: Full-time

Pay: $52,500.00 - $54,500.00 per year

Benefits:

• Dental insurance
• Employee assistance program
• Flexible schedule
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Professional development assistance
• Referral program
• Tuition reimbursement

Schedule:

• Day shift
• Monday to Friday

Work Location: Hybrid remote in Somerville, MA 02143

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