COMPANY OVERVIEW
Duffy Health Center, a non-profit located in Hyannis, MA, provides compassionate and skilled integrated healthcare for persons with complex health and social needs on Cape Cod. We envision a Cape Cod where all persons have access to quality health care, safe and stable housing, and lives filled with connection and purpose.
Duffy Health Center is a Federally Designated Healthcare for the Homeless Program. This requires that most of the patients we serve are experiencing or have recently experienced homelessness or some other form of housing insecurity.
Staff choose to work here because they believe deeply in the mission, and some staff have relevant lived experience themselves.
JOB OVERVIEW
The Care Manager will make an impact on the lives of people living with complex and/or chronic conditions, many of whom also face multiple barriers in their lives making it difficult for them to achieve improved health and well-being. This position requires flexibility, and responsibilities will vary from day-to-day. Outreach to patients may include telephonic or in person in a variety of settings such as but not limited to the health center, community, home or an inpatient facility.
KEY RESPONSIBILITIES
The essential functions or duties listed below are intended only as illustration of the various types of work that may be performed. The omission of specific statements of duties does not exclude them from the position if work is similar, related, or a logical assignment to the position.
- Conducts Comprehensive Assessments including assessing the member’s knowledge of their medical, behavioral health and/or social conditions and provides education and self-management support including symptom response plans based on the member’s needs and preferences.
- Assures that medication reconciliation is complete. The CM will complete the medication reconciliation and may include a pharmacist and/or primary care team.
- Engages members and care givers in active care planning with focus on medical, behavioral, social, member-centered care needs. Coaches and guides member/representative to meet bio/psycho/social goals.
- Provide care coordination, which may include but not limited to facilitating care transitions, supporting the completion of referrals, and/or providing or confirming appropriate follow-up.
- May meet enrollees in inpatient settings to provide education and support about the discharge process and transition members into care management.
- Connects members with primary care, behavioral health, flexible services, Community Partner, respite, and other community based social services as indicated and appropriate.
- In collaboration with Community Health Workers, creates and maintains a comprehensive inventory of local community resources, improving accessibility for members and providers, and linking members with the appropriate support services.
- Participates in the integrated care team meetings and rounds as required.
- Maintains accurate, timely documentation in electronic systems including health center electronic health records.
- Ensures right to privacy and confidentiality when releasing information about patients to others.
- Build relationships with partner agencies, community groups and organizations to strengthen network of resources available.
- May provide coverage as needed.
- Other duties as assigned
Population Served
- Unhoused
- Housing Insecure
- SUD & BH Clients
Qualifications & Skills
Education & Experience: (Required & Preferred)
- Associate’s degree in Social work, or Nursing, bachelor’s degree preferred.
- Master’s degree in social work, Mental Health Counseling, Licensed a plus
- 3 to 5 years of nursing or social work experience, preferably in home health, ambulatory care, community public health, case or care management coordinating across multiple settings with multiple providers
- Experience working in a community health center is strongly preferred, or otherwise experience working with the Medicare/Medicaid population
- Salary differential for bilingual staff that are certified in medical interpreting
Licenses/Certifications
- Current, active Massachusetts Registered Nurse license or LCSW, LICSW or LMHC preferred
- A valid driver's license and provision of a working vehicle
Skills & Competencies:
A candidate for this position should have:
Knowledge of:
- Nursing theory and practice
- Local groups and organizations providing health and social services
- Care management practices and procedures
- Issues related to homeless and at-risk individuals, including: mental illness, substance abuse, criminal history, and physical and sexual abuse
- The care needs of patients with complex medical and behavioral health conditions
- Protocol for handling crisis situations
- HIPAA regulations
- Trauma informed care
Skill in:
- Assessing and addressing the health needs of homeless and at-risk individuals
- Monitoring and managing client care
- Motivational interviewing
- Handling multiple priorities simultaneously in a timely manner
- Use clinical expertise in planning and problem solving
- Collecting and recording information and preparing reports
- Use of Microsoft Office suite and electronic health records
- Effective written and verbal communication
And ability to:
- Function in a multi-disciplinary team, valuing diverse perspectives and skill sets
- Communicate appropriately, responsibly and effectively with referral and community partners
- Work independently
- Be fiscally responsible in carrying out all care management functions and activities
- Maintain confidentiality of information
- Travel throughout assigned area to engage members at their homes or other locations where the member may be located.
- Commit to the philosophy and mission of Duffy Health Center which serves the homeless and at-risk population, and to the team-based approach as part of PCMH.
Supervision
Work is performed under the general direction of the Director of Behavioral Health and Care Management, with clinical oversight by the Director of Nursing and Clinical Operations. The employee plans and carries out the regular work in accordance with standard practices and previous training, with substantial responsibility for determining the sequence and timing of action and substantial independence in planning and organizing the work activities, including determining the work methods. The employee solves most problems of detail or unusual situations independently. Instructions for new assignments or special projects usually consist of statements of desired objectives, deadlines and priorities. Technical and policy problems or changes in procedures are discussed with supervisor. Work is generally reviewed only for technical adequacy, appropriateness of actions or decisions, and conformance with policy or other requirements; challenging or unique situations; resulting outcomes or activities. Supervision is provided both individually and in groups, with peers and supervisors.
Confidentiality
The employee has regular access at the departmental level to confidential medical records of patients.
Judgment
The work requires examining, analyzing and evaluating facts and circumstances surrounding individual problems, situations or transactions, and determining actions to be taken within the limits of standard or accepted practices. Guidelines include a large body of policies, practices and precedents which may be complex or conflicting, at times. Judgment is used in analyzing specific situations to determine appropriate actions. Employee is expected to weigh efficiency and relative priorities in conjunction with procedural concerns in decision making. Requires understanding, interpreting and applying complex federal, state and local regulations. Assignments typically involve evaluation and interpretation of factors, conditions or unusual circumstances.
Errors could result in delay or loss of service.
Complexity
The work consists of the practical application of a variety of concepts, practices and specialized techniques relating to a professional or technical field. Assignments typically involve evaluation and interpretation of factors, conditions or unusual circumstances; gathering, analyzing and evaluating facts or data using specialized fact-finding techniques; or determining the methods to accomplish the work.
Nature of Contacts
The position has constant contact with clients/patients, co-workers, and outside agencies and organizations in person, via email and on the phone. Services are provided in non-traditional settings. Some client meetings are office-based, via telehealth, some are in the field. The purpose for contact is to conduct interviews, collect data and information, advocate for patients and families/caregivers needs, resolve problems, make referrals, and give or receive information and assistance.
Work Environment/Physical Requirements:
Employee works in a health care office and out in the field while assisting clients. Employee is required to walk, sit, talk/listen and use hands more than 2/3 of the time; and stand and reach up to 1/3 of the time. Employee occasionally lifts up to 10 lbs. and may have occasion to up to 30 lbs. Normal vision is required for the position. Equipment operated includes office machines, automobile and computers. Employee may be exposed to hostile individuals and/or situations.
Why Join Duffy?
- Be part of a mission-driven team transforming health care for the most vulnerable.
- Advocate for services and systems that improve health equity for individuals experiencing homelessness.
- Help shape innovative patient-centred models of care.
Job Type: Full-time
Pay: $75,000.00 - $95,000.00 per year
Benefits:
- 403(b)
- Continuing education credits
- Dental insurance
- Health insurance
- Health savings account
- Life insurance
- Paid time off
- Tuition reimbursement
- Vision insurance
Experience:
- Nursing: 3 years (Preferred)
- Case management: 3 years (Preferred)
License/Certification:
Work Location: In person
