Overview Care Coordinator II Massachusetts Care Coordination Network, an Affiliate of Seven Hills Foundation The Care Coordinator II will provide coordinated Long-Term Services and Support (LTSS) care management services as an integrated member of care management team with a case load of up to 110 youth and adult Enrollees in need of services. In this role, you will coordinate and manage care for our service recipients providing essential support and services while maintaining quality, service excellence and ethical standards. Pay: $23/hour Benefits for Full-time employees: * Health Insurance: Offered through Blue Cross Blue Shield, with generous company contribution. * Enhanced Retirement Plan: 25% - 33% Employer match based on tenure. * Student Loan Assistance: Consolidation, counseling, & limited employer contribution! * Discounted Tuition with College & University Partnerships! * Tuition Assistance: Reimbursed or prepaid college coursework! * Home Mortgage Initiative: Favorable down payment (3-5%), reduced closing costs co-paid by Seven Hills! Work-Life Balance: * Generous Accrued Paid Vacation: 3 weeks in your first year! * Vacation Cash-Out Option * 3 Paid Personal Days * 11 Paid Holidays * Accrued Paid Sick Time Responsibilities * Collaborate with care teams and Enrollees to deliver high-quality LTSS (Long-Term Services and Supports) care management * Complete Comprehensive Assessments and develop/update LTSS Care Plans within required timelines * Monitor and update LTSS Care Plans based on changes in Enrollee's functional status (ADLs/IADLs) * Support Enrollees in understanding and directing their care planning process, including LTSS options and self-directed care * Provide information on available LTSS services and assist Enrollees in accessing programs for which they are eligible * Assess and identify social services and community resources to support Enrollee wellbeing * Conduct Flexible Services assessments for ACO Enrollees and recommend services to ACOs as appropriate * Coordinate services among healthcare, behavioral health, LTSS, and community providers to ensure integrated care * Participate in care team meetings to promote effective interdisciplinary communication * Provide health and wellness coaching as indicated in the LTSS Care Plan * Maintain ongoing contact with Enrollees, including quarterly face-to-face meetings, to monitor care coordination * Conduct home visits and follow-ups after hospital or diversionary setting discharges within required timeframes * Support care transitions by following up within 7 days after ED or inpatient discharges * Ensure updated and accurate contact information by reaching out to providers and collaterals when Enrollees are unreachable * Perform outreach and obtain missing demographic data as needed * Provide transition planning and post-discharge follow-up support * Complete timely and accurate documentation for all activities * Treat all Enrollees with dignity and respect, adhering to MCCN's Human Rights Policy * Adhere to all agency policies, procedures, and performance standards Qualifications Education & Experience: * BA in social work, human services, nursing, psychology, sociology, or related field from an accredited college/university OR an associate's degree and at least one-year professional experience in the field OR at least three years of relevant professional experience. * Experience working with individuals with complex LTSS needs and credentialled as a community health worker, health outreach worker, peer specialist, or recovery coach desired. * Care Coordination and Behavioral Health experience preferred. * Experience in navigating individual and family service systems and demonstrated the capacity to work collaboratively and effectively with families and community-based colleagues. Skills and Knowledge: * Ability to use Electronic Health Records (EHR) Systems to document and coordinate services. * Must be able to perform each essential duty satisfactorily. * Strong interpersonal skills in terms of developing a working relationship with a variety of individuals in a variety of context. Ability to communicate effectively verbally and in writing. * Strong organization skills with Attention to detail, multi-tasking skills, Prioritization skills, * Analytical skills, Problem-solving skills, and Team skills. * Strongly prefer that a candidate will have a demonstrated understanding of and competence of Health Equity and in serving culturally diverse populations. * Commitment to MCCN values and mission. * Ability to travel on a regular basis; Must have valid driver's license and access to an automobile. * Ability to read and speak English. Fluency in other languages, especially Spanish preferred. * Strongly preferred experience in Microsoft Products and software i.e., Excel, Word, Outlook, etc. Why Join Us?At Massachusetts Care Coordination Network, you'll make a meaningful impact on the lives of individuals served while working in a supportive and collaborative team environment. Apply Today!Take the next step in your career and join us as a Care Coordinator II