Complex Care Coordinator (BMC Clinic)

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  "detail": {
    "url": "https://bhchpjobs.applytojob.com/apply/jobs/details/paYE1ipVqv?&",
    "heading": "Complex Care Coordinator (BMC Clinic)",
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    "description_html": "<span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><b><u><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Who we are:</span></span></u></b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">  <br>Since 1985, BHCHP’s mission has been to ensure unconditionally equitable and dignified access to the highest quality health care for all individuals and families experiencing homelessness in greater Boston. Over 10,000 homeless individuals are cared for by Boston Health Care for the Homeless Program each year. We are committed to ensuring that every one of these individuals has access to comprehensive health care, from preventative dental care to cancer treatment. Our clinicians, case managers, and behavioral health professionals work in more than 30 locations to serve some of our community’s most vulnerable—and most resilient—citizens.<br><br>From our earliest days as a program, we have always sought to do work that is transformational: recognizing our shared humanity; centering dignity, compassion, mutual respect and supporting the right of every individual to access the highest levels of health care and every staff member to reach their fullest potential. We continue to be committed to building bridges and breaking down barriers, including systemic racism which harms us all. We provide community-based health care services that are compassionate, dignified, and culturally appropriate, incorporating social determinants of health, with the goal of breaking down the physical and systemic barriers that our patients face.</span></span></span></span><br><br><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><b><u><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Job Summary:</span></span></u></b></span></span><br><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Hours:<b>                   </b>In Person, 40 hours, Monday-Friday</span></span></span></span><br><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Union:                  Yes<br>Union Name:      1199SEIU<br>Patient Facing:    Yes</span></span>        </span></span><br><br><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Since 1985, the mission of Boston Health Care for the Homeless Program (BHCHP) has been to provide or assure access to the highest quality health care for all persons experiencing homelessness in the greater Boston area. By offering complex care management (CCM) services at BHCHP, our teams are able to extend supports to the outreach setting for a medically complex, mostly homeless group of patients who are not well engaged with primary care or behavioral health services. This role is designed to be better integrated with multi-disciplinary teams in BHCHP’s outpatient clinics to facilitate communication and collaboration on some of BHCHP’s most vulnerable patients. Complex care management requires compassionate, dignified, and culturally appropriate interactions with patients that have long been disenfranchised, incorporating social determinants of health, with the goal of breaking down the physical and systemic barriers that our patients face.</span></span></span></span><br><br><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">This <b>Complex Care Coordinator</b> will provide care coordination support for a panel of up to 25 high-risk primary care patients at Boston Health Care for the Homeless Program. This involves flexibility to provide patient care coordination at BMC Clinic as well as through mobile outreach to other settings where the patient frequents, resides, or otherwise receives care.  The Complex Care Coordinator will work with their supervisor to determine individualized outreach based on patient needs. </span></span></span></span><br><br><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Additionally, this individual will also work closely with an assigned primary care team at BMC Clinic, providing case management services to walk-in patients for about 50% of their time.</span></span></span></span><br><br><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><b><u><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Responsibilities:  </span></span></u></b></span></span><br><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><i><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">General</span></span></i></span></span><ul><li><span style=\"font-size:10pt;\"><span><span style=\"font-family:'Times New Roman', serif;\"><b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Work at BMC Clinic </span></span></b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">with a multidisciplinary team of providers, nurses, behavioral health clinicians, and case managers. </span></span></span></span></span></li><li><span style=\"font-size:10pt;\"><span><span style=\"font-family:'Times New Roman', serif;\"><b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">This position will include a combination</span></span></b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\"> of scheduled clinic sessions to see walk-in patients and outreach sessions as needed, with prior supervisor approval, to engage referred patients in the place where they frequent, receive care, and/or reside, and to accompany patients to appointments, court, etc. </span></span></span></span></span></li><li><span style=\"font-size:10pt;\"><span><span style=\"font-family:'Times New Roman', serif;\"><b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Document patient encounters</span></span></b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">, as well as all outreach attempts, in the electronic health record.</span></span></span></span></span></li><li><span style=\"font-size:10pt;\"><span><span style=\"font-family:'Times New Roman', serif;\"><b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Collaboratively develop, and document progress</span></span></b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\"> towards, patient-identified goals and a plan of care for each patient.</span></span></span></span></span></li><li><span style=\"font-size:10pt;\"><span><span style=\"font-family:'Times New Roman', serif;\"><b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Coordinate services</span></span></b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\"> <b>and assist patients with obtaining benefits</b>, housing, housing tenancy supports, transportation, and other services that address their health-related social needs.</span></span></span></span></span></li><li><span style=\"font-size:10pt;\"><span><span style=\"font-family:'Times New Roman', serif;\"><b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Support patients’ access to public health supplies</span></span></b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\"> by regularly stocking BHCHP’s public health vending machine and helping patients register for access to the machine.</span></span></span></span></span></li><li><span style=\"font-size:10pt;\"><span><span style=\"font-family:'Times New Roman', serif;\"><b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Develop and maintain awareness of community resources</span></span></b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\"> and services available to patients.</span></span></span></span></span></li><li><span style=\"font-size:10pt;\"><span><span style=\"font-family:'Times New Roman', serif;\"><b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Promote appointment adherence</span></span></b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\"> by assisting patients with scheduling and rescheduling missed medical and behavioral appointments, including specialty care, as needed. Support referrals to SUD treatment programs as needed.</span></span></span></span></span></li><li><span style=\"font-size:10pt;\"><span><span style=\"font-family:'Times New Roman', serif;\"><b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Identify and develop cooperative working relationships</span></span></b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\"> with service providers for people experiencing homelessness, and coordinate housing supports using Homeless Management Information Systems (HMIS) when appropriate.</span></span></span></span></span></li><li><span style=\"font-size:10pt;\"><span><span style=\"font-family:'Times New Roman', serif;\"><b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Work with patients to complete MassHealth applications</span></span></b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\"> and redeterminations to avoid disruptions to coverage. </span></span></span></span></span></li><li><span style=\"font-size:10pt;\"><span><span style=\"font-family:'Times New Roman', serif;\"><b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Successfully complete the MassHealth Certified Application Counselor exam (CAC)</span></span></b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\"> within 60 days of hire and maintain active certification status.</span></span></span></span></span></li></ul><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><i><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Complex Care Coordination for High-Risk Patients</span></span></i></span></span><br><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">In addition to the services outlined above:</span></span></span></span><ul><li><span style=\"font-size:10pt;\"><span><span style=\"font-family:'Times New Roman', serif;\"><b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Outreach and engagement:</span></span></b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\"> Make best efforts, using multiple attempts and modalities, to successfully outreach and engage newly assigned patients within 30 days of their assignment to the care management panel, or within other timeframes as determined by payor. </span></span></span></span></span></li><li><span style=\"font-size:10pt;\"><span><span style=\"font-family:'Times New Roman', serif;\"><b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Needs assessment:</span></span></b> <span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Complete intake, comprehensive needs assessment, and care plans for primary care patients referred by Accountable Care Organizations or internal care teams for high-risk care management. Update these documents at least annually or when the patient’s condition changes as required by the ACOs.</span></span></span></span></span></li><li><span style=\"font-size:10pt;\"><span><span style=\"font-family:'Times New Roman', serif;\"><b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Support during transitions of care:</span></span></b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\"> Provide intensive, timely care coordination to patients during transitions of care, including but not limited to participating, as appropriate, in discharge planning with inpatient health care providers. </span></span></span></span></span></li><li><span style=\"font-size:10pt;\"><span><span style=\"font-family:'Times New Roman', serif;\"><b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Follow-up after hospitalization:</span></span></b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\"> Follow up with patients face-to-face or by telephone following an inpatient or Emergency Department discharge to coordinate clinical and supportive services. </span></span></span></span></span></li><li><span style=\"font-size:10pt;\"><span><span style=\"font-family:'Times New Roman', serif;\"><b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Documentation:</span></span></b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\"> Follow billing, documentation, and assessment guidelines as required by payors.</span></span></span></span></span></li><li><span style=\"font-size:10pt;\"><span><span style=\"font-family:'Times New Roman', serif;\"><b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Use data</span></span></b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\"> to evaluate outcomes and adjust interventions as needed.</span></span></span></span></span></li><li><span style=\"font-size:10pt;\"><span><span style=\"font-family:'Times New Roman', serif;\"><b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Participate in weekly case conference meetings</span></span></b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\"> to discuss mutual patients with care team members to maintain integrated care model.</span></span></span></span></span></li><li><span style=\"font-size:10pt;\"><span><span style=\"font-family:'Times New Roman', serif;\"><b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Participate in ongoing training</span></span></b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\"> on care management principles and practices.</span></span></span></span></span></li></ul><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><b><u><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Qualifications:</span></span></u></b></span></span><ul><li><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">A bachelor’s degree in a behavioral health field (e.g., social work, human services, psychology, sociology, or related field); or at least three years of relevant professional experience.</span></span></span></span></li><li><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Able to work with multidisciplinary team maintaining a good rapport with nursing staff, medical staff, other departments, and visitors</span></span></span></span></li><li><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Strong problem solving and communication skills (written and oral)</span></span></span></span></li><li><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Excellent customer service skills and the ability to communicate professionally with employees and patients, both on the phone and in person</span></span></span></span></li><li><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Efficient, organized, detail-oriented, and able to complete tasks in a time-sensitive manner</span></span></span></span></li><li><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Self-directed with the ability to work independently in multiple settings</span></span></span></span></li><li><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Flexible and adaptable to different health care delivery models</span></span></span></span></li><li><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Knowledge of the network of services available to homeless persons, and experience working with homeless persons preferred</span></span></span></span></li><li><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Prior case management experience preferred</span></span></span></span></li><li><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Computer skills: proficient with Microsoft Office, including Microsoft Excel, and entering narrative and other data into electronic medical records and other internet-based products</span></span></span></span></li><li><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Spanish or Haitian Creole language skills strongly preferred </span></span></span></span></li><li><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Willingness to travel to outreach/various sites</span></span></span></span></li><li><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Valid driver’s license and car required or strongly recommended to travel to multiple sites</span></span></span></span></li></ul><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><b><u><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Compensation and Benefits:</span></span></u></b></span></span><ul><li><span style=\"font-size:10pt;\"><span><span style=\"font-family:'Times New Roman', serif;\"><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">The compensation increases based on years of experience and ranges from $22.25 - $35.60 hourly. </span></span></span></span></span></li><li><span style=\"font-size:10pt;\"><span><span style=\"font-family:'Times New Roman', serif;\"><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">BHCHP full time employees are eligible for our competitive time off program, health, dental and vision insurance, 403B retirement savings plan, pre-tax MBTA pass program with 40% discount, additional compensation for demonstrated bilingual proficiency and more.  Benefits are prorated for part-time employees.</span></span></span></span></span></li></ul><p><span style=\\\"font-size:14px\\\"><span style=\\\"font-family:Calibri,'sans-serif'\\\">Does this amazing opportunity interest you? Then we'd love to hear from you. </span></span></p>\n\n<p><span style=\\\"font-size:12px\\\">As an equal opportunity employer, Boston Health Care for the Homeless Program is committed to providing employment opportunities to all qualified individuals and does not discriminate on the basis of race, color, ethnicity, religion, sex, gender, gender identity and expression, sexual orientation, national origin, disability, age, marital status, veteran status, pregnancy, parental status, genetic information or characteristics, or any other basis prohibited by applicable law.</span></p>\n\n<p><em><strong><span style=\\\"font-size:14px\\\"><span style=\\\"font-family:Calibri,'sans-serif'\\\">Covid-19 Vaccination: Proof of Covid-19 vaccination(s) is optional for employment. Candidates who are offered employment will be given details about how to demonstrate receipt of vaccination if they choose to.</span></span></strong></em></p>\n\n<p><strong><em>Please Note: Employment at Boston Health Care for the Homeless is at-will. </em></strong><strong><em>Boston Health Care for the Homeless does not sponsor work authorization visas.</em></strong></p>\n\n<p> </p>\n\n<p> </p>\n\n<p> </p>\n\n<p> </p>",
    "description_text": "Who we are:\nSince 1985, BHCHP’s mission has been to ensure unconditionally equitable and dignified access to the highest quality health care for all individuals and families experiencing homelessness in greater Boston. Over 10,000 homeless individuals are cared for by Boston Health Care for the Homeless Program each year. We are committed to ensuring that every one of these individuals has access to comprehensive health care, from preventative dental care to cancer treatment. Our clinicians, case managers, and behavioral health professionals work in more than 30 locations to serve some of our community’s most vulnerable—and most resilient—citizens.\nFrom our earliest days as a program, we have always sought to do work that is transformational: recognizing our shared humanity; centering dignity, compassion, mutual respect and supporting the right of every individual to access the highest levels of health care and every staff member to reach their fullest potential. We continue to be committed to building bridges and breaking down barriers, including systemic racism which harms us all. We provide community-based health care services that are compassionate, dignified, and culturally appropriate, incorporating social determinants of health, with the goal of breaking down the physical and systemic barriers that our patients face.\n Job Summary:\n Hours:                    In Person, 40 hours, Monday-Friday\n Union:                  Yes\nUnion Name:      1199SEIU\nPatient Facing:    Yes\n Since 1985, the mission of Boston Health Care for the Homeless Program (BHCHP) has been to provide or assure access to the highest quality health care for all persons experiencing homelessness in the greater Boston area. By offering complex care management (CCM) services at BHCHP, our teams are able to extend supports to the outreach setting for a medically complex, mostly homeless group of patients who are not well engaged with primary care or behavioral health services. This role is designed to be better integrated with multi-disciplinary teams in BHCHP’s outpatient clinics to facilitate communication and collaboration on some of BHCHP’s most vulnerable patients. Complex care management requires compassionate, dignified, and culturally appropriate interactions with patients that have long been disenfranchised, incorporating social determinants of health, with the goal of breaking down the physical and systemic barriers that our patients face.\n This Complex Care Coordinator will provide care coordination support for a panel of up to 25 high-risk primary care patients at Boston Health Care for the Homeless Program. This involves flexibility to provide patient care coordination at BMC Clinic as well as through mobile outreach to other settings where the patient frequents, resides, or otherwise receives care.  The Complex Care Coordinator will work with their supervisor to determine individualized outreach based on patient needs.\n Additionally, this individual will also work closely with an assigned primary care team at BMC Clinic, providing case management services to walk-in patients for about 50% of their time.\n Responsibilities:\n General Work at BMC Clinic with a multidisciplinary team of providers, nurses, behavioral health clinicians, and case managers.\n This position will include a combination of scheduled clinic sessions to see walk-in patients and outreach sessions as needed, with prior supervisor approval, to engage referred patients in the place where they frequent, receive care, and/or reside, and to accompany patients to appointments, court, etc.\n Document patient encounters , as well as all outreach attempts, in the electronic health record.\n Collaboratively develop, and document progress towards, patient-identified goals and a plan of care for each patient.\n Coordinate services and assist patients with obtaining benefits , housing, housing tenancy supports, transportation, and other services that address their health-related social needs.\n Support patients’ access to public health supplies by regularly stocking BHCHP’s public health vending machine and helping patients register for access to the machine.\n Develop and maintain awareness of community resources and services available to patients.\n Promote appointment adherence by assisting patients with scheduling and rescheduling missed medical and behavioral appointments, including specialty care, as needed. Support referrals to SUD treatment programs as needed.\n Identify and develop cooperative working relationships with service providers for people experiencing homelessness, and coordinate housing supports using Homeless Management Information Systems (HMIS) when appropriate.\n Work with patients to complete MassHealth applications and redeterminations to avoid disruptions to coverage.\n Successfully complete the MassHealth Certified Application Counselor exam (CAC) within 60 days of hire and maintain active certification status.\n Complex Care Coordination for High-Risk Patients\n In addition to the services outlined above: Outreach and engagement: Make best efforts, using multiple attempts and modalities, to successfully outreach and engage newly assigned patients within 30 days of their assignment to the care management panel, or within other timeframes as determined by payor.\n Needs assessment: Complete intake, comprehensive needs assessment, and care plans for primary care patients referred by Accountable Care Organizations or internal care teams for high-risk care management. Update these documents at least annually or when the patient’s condition changes as required by the ACOs.\n Support during transitions of care: Provide intensive, timely care coordination to patients during transitions of care, including but not limited to participating, as appropriate, in discharge planning with inpatient health care providers.\n Follow-up after hospitalization: Follow up with patients face-to-face or by telephone following an inpatient or Emergency Department discharge to coordinate clinical and supportive services.\n Documentation: Follow billing, documentation, and assessment guidelines as required by payors.\n Use data to evaluate outcomes and adjust interventions as needed.\n Participate in weekly case conference meetings to discuss mutual patients with care team members to maintain integrated care model.\n Participate in ongoing training on care management principles and practices.\n Qualifications: A bachelor’s degree in a behavioral health field (e.g., social work, human services, psychology, sociology, or related field); or at least three years of relevant professional experience.\n Able to work with multidisciplinary team maintaining a good rapport with nursing staff, medical staff, other departments, and visitors\n Strong problem solving and communication skills (written and oral)\n Excellent customer service skills and the ability to communicate professionally with employees and patients, both on the phone and in person\n Efficient, organized, detail-oriented, and able to complete tasks in a time-sensitive manner\n Self-directed with the ability to work independently in multiple settings\n Flexible and adaptable to different health care delivery models\n Knowledge of the network of services available to homeless persons, and experience working with homeless persons preferred\n Prior case management experience preferred\n Computer skills: proficient with Microsoft Office, including Microsoft Excel, and entering narrative and other data into electronic medical records and other internet-based products\n Spanish or Haitian Creole language skills strongly preferred\n Willingness to travel to outreach/various sites\n Valid driver’s license and car required or strongly recommended to travel to multiple sites\n Compensation and Benefits: The compensation increases based on years of experience and ranges from $22.25 - $35.60 hourly.\n BHCHP full time employees are eligible for our competitive time off program, health, dental and vision insurance, 403B retirement savings plan, pre-tax MBTA pass program with 40% discount, additional compensation for demonstrated bilingual proficiency and more.  Benefits are prorated for part-time employees.\n Does this amazing opportunity interest you? Then we'd love to hear from you.\n As an equal opportunity employer, Boston Health Care for the Homeless Program is committed to providing employment opportunities to all qualified individuals and does not discriminate on the basis of race, color, ethnicity, religion, sex, gender, gender identity and expression, sexual orientation, national origin, disability, age, marital status, veteran status, pregnancy, parental status, genetic information or characteristics, or any other basis prohibited by applicable law.\n Covid-19 Vaccination: Proof of Covid-19 vaccination(s) is optional for employment. Candidates who are offered employment will be given details about how to demonstrate receipt of vaccination if they choose to.\n Please Note: Employment at Boston Health Care for the Homeless is at-will. Boston Health Care for the Homeless does not sponsor work authorization visas.",
    "jsonld_jobposting": {
      "url": "https://bhchpjobs.applytojob.com/apply/paYE1ipVqv/Complex-Care-Coordinator-BMC-Clinic",
      "@type": "JobPosting",
      "title": "Complex Care Coordinator (BMC Clinic)",
      "@context": "http://schema.org/",
      "datePosted": "2026-05-20",
      "description": "<span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><b><u><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Who we are:</span></span></u></b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">  <br>Since 1985, BHCHP’s mission has been to ensure unconditionally equitable and dignified access to the highest quality health care for all individuals and families experiencing homelessness in greater Boston. Over 10,000 homeless individuals are cared for by Boston Health Care for the Homeless Program each year. We are committed to ensuring that every one of these individuals has access to comprehensive health care, from preventative dental care to cancer treatment. Our clinicians, case managers, and behavioral health professionals work in more than 30 locations to serve some of our community’s most vulnerable—and most resilient—citizens.<br><br>From our earliest days as a program, we have always sought to do work that is transformational: recognizing our shared humanity; centering dignity, compassion, mutual respect and supporting the right of every individual to access the highest levels of health care and every staff member to reach their fullest potential. We continue to be committed to building bridges and breaking down barriers, including systemic racism which harms us all. We provide community-based health care services that are compassionate, dignified, and culturally appropriate, incorporating social determinants of health, with the goal of breaking down the physical and systemic barriers that our patients face.</span></span></span></span><br><br><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><b><u><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Job Summary:</span></span></u></b></span></span><br><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Hours:<b>                   </b>In Person, 40 hours, Monday-Friday</span></span></span></span><br><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Union:                  Yes<br>Union Name:      1199SEIU<br>Patient Facing:    Yes</span></span>        </span></span><br><br><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Since 1985, the mission of Boston Health Care for the Homeless Program (BHCHP) has been to provide or assure access to the highest quality health care for all persons experiencing homelessness in the greater Boston area. By offering complex care management (CCM) services at BHCHP, our teams are able to extend supports to the outreach setting for a medically complex, mostly homeless group of patients who are not well engaged with primary care or behavioral health services. This role is designed to be better integrated with multi-disciplinary teams in BHCHP’s outpatient clinics to facilitate communication and collaboration on some of BHCHP’s most vulnerable patients. Complex care management requires compassionate, dignified, and culturally appropriate interactions with patients that have long been disenfranchised, incorporating social determinants of health, with the goal of breaking down the physical and systemic barriers that our patients face.</span></span></span></span><br><br><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">This <b>Complex Care Coordinator</b> will provide care coordination support for a panel of up to 25 high-risk primary care patients at Boston Health Care for the Homeless Program. This involves flexibility to provide patient care coordination at BMC Clinic as well as through mobile outreach to other settings where the patient frequents, resides, or otherwise receives care.  The Complex Care Coordinator will work with their supervisor to determine individualized outreach based on patient needs. </span></span></span></span><br><br><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Additionally, this individual will also work closely with an assigned primary care team at BMC Clinic, providing case management services to walk-in patients for about 50% of their time.</span></span></span></span><br><br><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><b><u><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Responsibilities:  </span></span></u></b></span></span><br><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><i><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">General</span></span></i></span></span><ul><li><span style=\"font-size:10pt;\"><span><span style=\"font-family:'Times New Roman', serif;\"><b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Work at BMC Clinic </span></span></b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">with a multidisciplinary team of providers, nurses, behavioral health clinicians, and case managers. </span></span></span></span></span></li><li><span style=\"font-size:10pt;\"><span><span style=\"font-family:'Times New Roman', serif;\"><b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">This position will include a combination</span></span></b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\"> of scheduled clinic sessions to see walk-in patients and outreach sessions as needed, with prior supervisor approval, to engage referred patients in the place where they frequent, receive care, and/or reside, and to accompany patients to appointments, court, etc. </span></span></span></span></span></li><li><span style=\"font-size:10pt;\"><span><span style=\"font-family:'Times New Roman', serif;\"><b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Document patient encounters</span></span></b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">, as well as all outreach attempts, in the electronic health record.</span></span></span></span></span></li><li><span style=\"font-size:10pt;\"><span><span style=\"font-family:'Times New Roman', serif;\"><b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Collaboratively develop, and document progress</span></span></b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\"> towards, patient-identified goals and a plan of care for each patient.</span></span></span></span></span></li><li><span style=\"font-size:10pt;\"><span><span style=\"font-family:'Times New Roman', serif;\"><b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Coordinate services</span></span></b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\"> <b>and assist patients with obtaining benefits</b>, housing, housing tenancy supports, transportation, and other services that address their health-related social needs.</span></span></span></span></span></li><li><span style=\"font-size:10pt;\"><span><span style=\"font-family:'Times New Roman', serif;\"><b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Support patients’ access to public health supplies</span></span></b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\"> by regularly stocking BHCHP’s public health vending machine and helping patients register for access to the machine.</span></span></span></span></span></li><li><span style=\"font-size:10pt;\"><span><span style=\"font-family:'Times New Roman', serif;\"><b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Develop and maintain awareness of community resources</span></span></b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\"> and services available to patients.</span></span></span></span></span></li><li><span style=\"font-size:10pt;\"><span><span style=\"font-family:'Times New Roman', serif;\"><b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Promote appointment adherence</span></span></b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\"> by assisting patients with scheduling and rescheduling missed medical and behavioral appointments, including specialty care, as needed. Support referrals to SUD treatment programs as needed.</span></span></span></span></span></li><li><span style=\"font-size:10pt;\"><span><span style=\"font-family:'Times New Roman', serif;\"><b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Identify and develop cooperative working relationships</span></span></b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\"> with service providers for people experiencing homelessness, and coordinate housing supports using Homeless Management Information Systems (HMIS) when appropriate.</span></span></span></span></span></li><li><span style=\"font-size:10pt;\"><span><span style=\"font-family:'Times New Roman', serif;\"><b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Work with patients to complete MassHealth applications</span></span></b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\"> and redeterminations to avoid disruptions to coverage. </span></span></span></span></span></li><li><span style=\"font-size:10pt;\"><span><span style=\"font-family:'Times New Roman', serif;\"><b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Successfully complete the MassHealth Certified Application Counselor exam (CAC)</span></span></b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\"> within 60 days of hire and maintain active certification status.</span></span></span></span></span></li></ul><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><i><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Complex Care Coordination for High-Risk Patients</span></span></i></span></span><br><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">In addition to the services outlined above:</span></span></span></span><ul><li><span style=\"font-size:10pt;\"><span><span style=\"font-family:'Times New Roman', serif;\"><b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Outreach and engagement:</span></span></b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\"> Make best efforts, using multiple attempts and modalities, to successfully outreach and engage newly assigned patients within 30 days of their assignment to the care management panel, or within other timeframes as determined by payor. </span></span></span></span></span></li><li><span style=\"font-size:10pt;\"><span><span style=\"font-family:'Times New Roman', serif;\"><b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Needs assessment:</span></span></b> <span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Complete intake, comprehensive needs assessment, and care plans for primary care patients referred by Accountable Care Organizations or internal care teams for high-risk care management. Update these documents at least annually or when the patient’s condition changes as required by the ACOs.</span></span></span></span></span></li><li><span style=\"font-size:10pt;\"><span><span style=\"font-family:'Times New Roman', serif;\"><b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Support during transitions of care:</span></span></b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\"> Provide intensive, timely care coordination to patients during transitions of care, including but not limited to participating, as appropriate, in discharge planning with inpatient health care providers. </span></span></span></span></span></li><li><span style=\"font-size:10pt;\"><span><span style=\"font-family:'Times New Roman', serif;\"><b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Follow-up after hospitalization:</span></span></b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\"> Follow up with patients face-to-face or by telephone following an inpatient or Emergency Department discharge to coordinate clinical and supportive services. </span></span></span></span></span></li><li><span style=\"font-size:10pt;\"><span><span style=\"font-family:'Times New Roman', serif;\"><b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Documentation:</span></span></b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\"> Follow billing, documentation, and assessment guidelines as required by payors.</span></span></span></span></span></li><li><span style=\"font-size:10pt;\"><span><span style=\"font-family:'Times New Roman', serif;\"><b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Use data</span></span></b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\"> to evaluate outcomes and adjust interventions as needed.</span></span></span></span></span></li><li><span style=\"font-size:10pt;\"><span><span style=\"font-family:'Times New Roman', serif;\"><b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Participate in weekly case conference meetings</span></span></b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\"> to discuss mutual patients with care team members to maintain integrated care model.</span></span></span></span></span></li><li><span style=\"font-size:10pt;\"><span><span style=\"font-family:'Times New Roman', serif;\"><b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Participate in ongoing training</span></span></b><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\"> on care management principles and practices.</span></span></span></span></span></li></ul><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><b><u><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Qualifications:</span></span></u></b></span></span><ul><li><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">A bachelor’s degree in a behavioral health field (e.g., social work, human services, psychology, sociology, or related field); or at least three years of relevant professional experience.</span></span></span></span></li><li><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Able to work with multidisciplinary team maintaining a good rapport with nursing staff, medical staff, other departments, and visitors</span></span></span></span></li><li><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Strong problem solving and communication skills (written and oral)</span></span></span></span></li><li><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Excellent customer service skills and the ability to communicate professionally with employees and patients, both on the phone and in person</span></span></span></span></li><li><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Efficient, organized, detail-oriented, and able to complete tasks in a time-sensitive manner</span></span></span></span></li><li><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Self-directed with the ability to work independently in multiple settings</span></span></span></span></li><li><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Flexible and adaptable to different health care delivery models</span></span></span></span></li><li><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Knowledge of the network of services available to homeless persons, and experience working with homeless persons preferred</span></span></span></span></li><li><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Prior case management experience preferred</span></span></span></span></li><li><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Computer skills: proficient with Microsoft Office, including Microsoft Excel, and entering narrative and other data into electronic medical records and other internet-based products</span></span></span></span></li><li><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Spanish or Haitian Creole language skills strongly preferred </span></span></span></span></li><li><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Willingness to travel to outreach/various sites</span></span></span></span></li><li><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Valid driver’s license and car required or strongly recommended to travel to multiple sites</span></span></span></span></li></ul><span style=\"font-size:10pt;\"><span style=\"font-family:'Times New Roman', serif;\"><b><u><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">Compensation and Benefits:</span></span></u></b></span></span><ul><li><span style=\"font-size:10pt;\"><span><span style=\"font-family:'Times New Roman', serif;\"><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">The compensation increases based on years of experience and ranges from $22.25 - $35.60 hourly. </span></span></span></span></span></li><li><span style=\"font-size:10pt;\"><span><span style=\"font-family:'Times New Roman', serif;\"><span style=\"font-size:11pt;\"><span style=\"font-family:Calibri, sans-serif;\">BHCHP full time employees are eligible for our competitive time off program, health, dental and vision insurance, 403B retirement savings plan, pre-tax MBTA pass program with 40% discount, additional compensation for demonstrated bilingual proficiency and more.  Benefits are prorated for part-time employees.</span></span></span></span></span></li></ul><p><span style=\\\"font-size:14px\\\"><span style=\\\"font-family:Calibri,'sans-serif'\\\">Does this amazing opportunity interest you? Then we'd love to hear from you. </span></span></p>\n\n<p><span style=\\\"font-size:12px\\\">As an equal opportunity employer, Boston Health Care for the Homeless Program is committed to providing employment opportunities to all qualified individuals and does not discriminate on the basis of race, color, ethnicity, religion, sex, gender, gender identity and expression, sexual orientation, national origin, disability, age, marital status, veteran status, pregnancy, parental status, genetic information or characteristics, or any other basis prohibited by applicable law.</span></p>\n\n<p><em><strong><span style=\\\"font-size:14px\\\"><span style=\\\"font-family:Calibri,'sans-serif'\\\">Covid-19 Vaccination: Proof of Covid-19 vaccination(s) is optional for employment. Candidates who are offered employment will be given details about how to demonstrate receipt of vaccination if they choose to.</span></span></strong></em></p>\n\n<p><strong><em>Please Note: Employment at Boston Health Care for the Homeless is at-will. </em></strong><strong><em>Boston Health Care for the Homeless does not sponsor work authorization visas.</em></strong></p>\n\n<p> </p>\n\n<p> </p>\n\n<p> </p>\n\n<p> </p>",
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