Care Coordinator

Family Service Association - Fall River - Brockton, MA (30+ days ago)


Family Service Association is a comprehensive private, non-profit social service agency dedicated to the development and implementation of services designed to provide strength and support to individuals and families throughout southeastern Massachusetts. Headquartered in Fall River, Family Service Association strives to increase the capacity of individuals and families to cope with the stresses of family life and interpersonal relationships in a positive, productive and health-improving manner. This agency is a leading provider of professional social services in the South Coast region of Massachusetts, with a 125-year tradition of high quality.

Due to Agency growth, we have a full time (35 hours per week) Care Coordinator position in our Long Term Services and Supports (LTSS) Community Partner (CP) program in the Brockton Area.

The Care Coordinator is responsible for promoting coordination in the delivery and receipt of LTSS to enrollees assigned by Accountable Care Organizations (ACO) and Managed Care Organizations (MCO).

Responsibilities include:
Conduct outreach to assigned enrollees to inform about the functions of a CP Care Coordinator, the optional nature of CP enrollment, choice in CP providers, the benefits of enrollment and the process for enrolling.
Document all outreach attempts including 3 separate attempts; and at least one face-to-face attempt unless the enrollee voices a preference for only telephonic contact.
Execute all required documents for participation in the CP program including but not limited to a Participation Form and all required authorizations for Use and Disclosure.
Obtain the Comprehensive Assessment from the referring ACO/MCO and update as needed for any changes in functional status, ADL or IADL needs.
Utilizing the Comprehensive Assessment, and under the direction of the enrollee/authorized representative, develop a LTSS Care Plan that identifies preferences, goals, strengths, needs and cultural considerations and is signed by the enrollee/authorized representative. Complete updates to the LTSS Care Plan upon request of the enrollee, as needed due to major changes in functional, ADL or IADL status, and at least every 12 months
Ensure LTSS Care Plan is approved by the Primary Care Provider and shared with all members of the enrollees care team including providers, members of state agencies and other case managers within 90 days of assignment.
Utilize alternative methods and formats of documentation and communication to ensure the enrollee understand the LTSS Care Plan; including but not limited to accommodation for sensory disabilities, literacy and primary language of the enrollee.
Utilize appropriate interventions to engage and support the enrollee in development of the LTSS Care Plan including self-directed care options and informed choice for applicable services, programs and providers.
Assess enrollees for Social Services and resources including Flexible Services and facilitate access to Social Services and Community Resources.
Participate as a member of the enrollees care team, providing subject matter expertise to the care team about LTSS, the enrollee’s needs, preferences and service options; advocating for appropriate care, facilitating communication with other providers and promoting integration of care across all spectrums.
Maintain regular contact with the enrollee and a minimum of one face-to-face contact quarterly to assist the enrollee to navigate and access needed services, providing ongoing monitoring of the implementation of the LTSS Care Plan and monitoring for changes in status including health, housing, natural supports and caregivers.
Provide support for transitions of care and facilitate the development of appropriate discharge plans as indicated.
Conduct follow-up within 3 business days following any transition in care and conduct a face-to-face visit with enrollees within 3 business days post discharge from any facility.
Maintain all documentation required for the delivery of LTSS Community Partner services.
Foster and maintain collaborative relationships with Primary Care Providers, Social Service Providers and representatives from state agencies.

The ideal candidate must have a Bachelor's Degree in social work, human services, nursing, psychology, sociology, or a related field; or, an Associate’s Degree and at least year of experience in the field.

Must have strong written and oral communication skills and demonstrated computer skills.

  • Bilingual - Spanish speaking a plus*
This is a benefits eligible position. Benefits include medical, dental, vision insurance, long term, short term disability, life insurance, 403(b), flexible spending account and a generous time off package including eleven paid holidays.

****This position includes a sign on bonus. *****

The hours are Monday through Friday, 9:00 a.m. - 5:00 p.m.

Spanish speaking applicants are encouraged to apply.

Family Service Association is an Equal Opportunity Employer.

***Please include salary range when applying.