Company Description: Innovative Care Partners (ICP) is a Community Partner servicing MassHealth Enrollees in the four counties of Western Massachusetts. It is a limited liability corporation established by three long-standing, well-respected local behavioral health and social service agencies to specifically respond to the needs of the MassHealth population in managing health and controlling costs. Center for Human Development (CHD), Gándara Center, and ServiceNet have joined forces as ICP in order to get the best health outcomes for Enrollees in this transformative, cutting edge approach to health care reform.
health care - Preference: Preferred
Would you like to dramatically improve the quality of life and health for people in your community? Innovative Care Partners is excited to be a part of an evolving model of healthcare that puts the patient at the center of their own care, and provides significant resources to help them achieve better wellness outcomes. The Care Coordinator is a key position in the success of this integrated-care model, working closely with patients in providing them the tools and resources they need for overall wellness.
This position will be located in PITTSFIELD, MASS.
The Care Coordinator works in collaboration with the multidisciplinary members of the care team to assist the assigned enrollee to achieve the goals outlined in the care plan. The Care Coordinator functions as an advocate and coach for enrollees who require additional support to meaningfully address social, psychological and medical needs.
• Collaborates with the care team (registered nurse, medical director, behavioral health specialists, social workers, etc.) to support enrollees; works with enrollees to identify and achieve shared treatment goals
• Assists enrollees to follow treatment recommendations, practice healthy behaviors and access necessary social and medical support services and programs (AA meetings, support groups, etc.)
• Links enrollees with resources and empowers them to use them to their advantage
• Uses recovery strategies such as motivational interviewing, harm reduction and strength based approaches to support enrollees in attaining stated goals
• Conducts visits in the home or in other locations in the community, either alone or with other members of the care team, to provide guidance, support, education and coaching. Follows up by telephone as necessary.
• Accompanies enrollees to medical appointments as requested; facilitates effective navigation of the health care system
• Escorts enrollees to pharmacy, grocery store, food pantry and other community locations as needed to meet care plan goals
• Arranges for translation services as needed and helps tailor information to literacy level on topics such as medication adherence, nutrition, exercise, fall prevention, home safety, substance abuse, advance directives
• Additional duties may include: checking/recording vital signs, teaching members to fill medication box, teaching members to prepare questions for doctor’s visit, transporting lab specimens to appropriate laboratory, participating in family meetings, participate in community outreach events
• Accurately document member encounters in medical record in a timely manner
• Participate in team meetings and communicate with members of the care team, proactively reporting changes or concerns and seeking guidance and support.
• Adhere to all applicable compliance requirements and the agency’s Code of Conduct
• Two years of experience in community based outreach, recovery coaching, peer specialist role, behavioral health, etc.
• Bachelor’s Degree in human services or behavioral health related field
• Strong interpersonal and customer relations skills
• Effective teaching skills
• Ability to work with people from diverse backgrounds and experiences
• Knowledge regarding psychiatric rehab, substance use, and understanding of recovery model
• Demonstrated computer literacy
• Bilingual - English/Spanish preferred
• Ability to make visits in a home-based setting
• Demonstrates empathy, compassion and care
• Ability to work in a fast-paced environment
• Ability to work independently and as part of a team
• Must have a vehicle available for work purposes