Clinical Care Partner - Health Home
Bay Cove Human Services, Inc.

Boston, Massachusetts

Posted in Community Services


Job Info


Mission Statement:

Bay Cove Human Services partners with people to overcome challenges and realize personal potential.

Job Summary:

The Clinical Care Partner acts as a liaison between the health insurer, Commonwealth Care Alliance, community providers, and Bay Cove staff. The Clinical Care Partner coordinates all aspects of medical and psychiatric care for those receiving services from Bay Cove Human Services that are enrolled in CCA's One Care Plan; coordinates and facilitates Interdisciplinary Care Team (ICT) meetings and other activities of the ICT; participates in the Initial Health Needs Assessments of each member; facilitates the development of an Integrated Care Plan (ICP) for each member; educates people about CCA One Care program benefits, services and supports; provides assessments as needed; coaches self-management skills as needed; and facilitates access to community services. The Clinical Care Partner collaborates with CCAs Clinical Team and Bay Cove in order to maximize the goal of medical and psychiatric care integration for clients. As the driver of the Interdisciplinary Care Team (ICT), the Clinical Care Partner provides the highest quality and continuity of care for members. This is an exempt position.

Essential Functions of Position:
The essential job duties/responsibilities of the position include but are not limited to the information listed below:

The Clinical Care Partner partners with both the Clinical team of CCA and contracted Partners in the provision of intensive case management and coordination for clients with complex needs.

  • Conducts assessments of clinical health risk and needs, as well as of clients' strengths, preferences and preferred family and community supports and develops member directed care plan which is then documented into CCA's care management platforms (Altruista's Guiding care and eCW);
  • Directs the planning, coordination, implementation, monitoring and review of the member's care plans, including health care strategies;
  • Offers the services of an LTSS Coordinator, and arranges for LTSS Coordinator participation in the assessment, care planning and ongoing Interdisciplinary Care Team (ICT) activities. Facilitates the effective functioning of the Interdisciplinary Care Team (ICT), including coordinating meetings, facilitating communication and documentation;
  • Collaborate closely with PCP and other Providers including, but not limited to community resources, and ensure appropriate referrals based on level of care needed to optimize outcomes and minimize risk;
  • Reviews and monitors ICPs and accompanying strategies developed by the team.
  • Effectively communicates any proposed changes in services, hospitalizations, medication changes, transitions of care, crisis intervention, and changes in patient level to all ICT members.
  • Obtains required prior authorization from CCA;
  • Provides coaching and support to clients as needed.
  • Educates members about program benefits, services and community supports and services.
  • Follows
  • Supports safe transitions for members moving between care settings, including but not limited to hospital to home, hospital to rehabilitation settings, rehabilitation settings to home, hospital to shelters, substance abuse treatment programs to community residence programs;
  • Conducts medication review and reconciliation.
  • Ensures timely information exchange, coordination and integration of care;
  • Maintains frequent member contact, as indicated.
Requirements for the position:
  • LICSW, LCSW or Registered Nurse licensed in the Commonwealth of Massachusetts.
  • Experience working with people with psychiatric disability, co-occurring disorders and complex medical needs preferred.
  • Minimum of 2 years clinical and case management experienced preferred.
  • Effective skills in managing, teaching, negotiating, and collaborating with multidisciplinary teams and member/family focus.
  • Strong time management skills.
  • Excellent written and oral communication skills.
  • Familiarity with EMR and electronic data collection systems such as eCW and Altruista's Guiding Care.
  • Strong organizational skills.
  • Knowledge of trauma-informed and culturally competent services
  • Sensitivity to the cultural, religious, ethnic, disability and gender issues
  • Skills and competence to establish supportive trusting relationships with members
  • Knowledge of empowerment and self-advocacy techniques
  • Knowledge of available community health and mental health services and resources
  • Knowledge of formal and informal assessment practices
  • Ability to triage/balance competing priorities
  • Ability to make independent judgments and decisions
  • Ability to work in a professional and confidential capacity
  • Knowledge of personal computer applications and equipment
  • A COVID-19 vaccination is a requirement of the position. One COVID-19 shot is acceptable, contingent on the individual receiving the second shot within the allotted time frame.

Personal Characteristics:
  • Ability to work collaboratively as a member of multidisciplinary and cross-functional teams.
  • Ability to function as an effective change agent.
  • Ability to negotiate and resolve differences.
  • Ability to function under pressure in a fast paced human service environment.
  • Ability to be flexible, open and responsive to ongoing industry changes.
  • Ability to articulate and communicate Bay Cove's mission and strategic direction in a consistent and enthusiastic manner.
  • Ability to effectively represent the Agency in a variety of circumstances and forums.
  • Ability to identify opportunities and obstacles and develop effective, creative solutions to pursue opportunities.
Physical Requirements
  • Ability to lift up to 50 pounds, to stoop, kneel, crouch, or crawl and to reach with hands and arms

Other Qualifications:

Driving Requirements:

Driving is a requirement for this position using a personal vehicle. You must possess and maintain adequate insurance as well as maintain a safe driving record which is subject to annual checks. A valid driver's license must be presented at the time of employment. Applicants must be at least 21 years of age, have maintained a valid US driver's license for at least one year, and must be able to pass a driver's screening background check.



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