Community Health Worker- Taunton

Bay Cove Human Services' mission is to partner with people to overcome challenges and realize personal potential. Bay Cove pursues this mission by providing individualized and compassionate services to people facing the challenges associated with developmental disabilities, mental illness, substance use disorders, and homelessness at more than 175 program sites throughout Greater Boston and Southeastern Massachusetts.

Job Summary :

The Community Health Worker I (CHW I) provides care coordination and care management for MassHealth Members with complex medical and behavioral health needs who are enrolled in an Accountable Care Organization (ACO) or Managed Care Organization (MCO) plan. The CHW I collaborates with the 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, Community First and SAMHSA Recovery Principles. The CHW I is at the helm of organizing and coordinating resources and services in response to the Enrollee's healthcare needs across multiple settings, and inclusive of both LTSS and SDH needs. This role drives assessment and care planning, care transitions, health and wellness coaching, as well as community and social services connections in partnership with Enrollees and their care teams.

This is a non-exempt position.

Job Responsibilities :

• Outreach to and engage Enrollees of an ACO plan as referred to CP Program.
• Coordinate the completion of the Comprehensive Assessment (CA).
• Conduct initial and ongoing risk assessment; design personal crisis management plans, relapse prevention and harm reduction strategies with members who have been identified as behaviorally complex in collaboration with team LPHAs.
• Coordinate the development, implementation, and ongoing review of the Person-Centered Treatment Plan (PCTP) inclusive of any LTSS and / or SDH needs or goals of the Enrollee.
• Drive referrals regarding connections to any community or social services that align with the Enrollees needs and goals.
• Submit CA, PCTP and all PCTP updates in accordance with the data sharing agreement CP and ACO / MCO Plan.
• Collaborate closely with PCP and other providers, including but not limited to community resources, to assure appropriate referrals based on level of care needed to optimize outcomes and minimize risk.
• Communicate and collaborate with ACO / MCO teams and serve as a team resource.
• Collaborate with ACO Plan, PCP and other health care providers regarding changes in services, care transitions, crisis intervention while focusing on continuity and quality of client care and potential efficiencies and cost-savings.
• Obtain required Prior Authorization from ACO / MCO Plan for relevant / necessary services.
• Manage all care transitions through collaboration with Enrollee, community provider staff, ICT and hospital staff to ensure a safe discharge plan and a well-coordinated implementation of that plan.
• Ensure completion of medication review by team RN as triggered by a care transition or by a medication change through an outpatient medical or psychiatric visit.
• Perform other duties, as required.

Requirements for the Position :

Bay Cove Human Services is an Equal Opportunity Employer and does not discriminate on the basis of race, ethnicity, religion, sex, gender identity or expression, national origin, sexual orientation, disability, age, veteran status, or any other groups as protected by Massachusetts or federal law. All qualified candidates, regardless of background, are encouraged to apply.

Bay Cove Human Services does not offer visa sponsorships at this time and will require candidates to be authorized to work in the United States.

Pay Rate : $24.04

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