Clinical Care Manager Central/Worcester MA(Part-Time) (Transportation)

Title: Clinical Care Manager
Reports to: Manager of Care Management
Classification: Individual Contributor
Location: Central, MA
Job description revision number and date: V 3.0; 11.18.2024

Organization Summary:
Community Care Cooperative (C3) is a 501(c)(3) non-profit, Accountable Care Organization (ACO) governed by Federally Qualified Health Centers (FQHCs). Our mission is to leverage the collective strengths of FQHCs to improve the health and wellness of the people we serve. We are a fast-growing organization founded in 2016 with 9 health centers and now serving hundreds of thousands of beneficiaries who receive primary care at health centers and independent practices across Massachusetts. We are an innovative organization developing new partnerships and programs to improve the health of members and communities, and to strengthen our health center partners.

Job Summary:
As an integral member of the care management team the Clinical Care Manager (CM) will have the opportunity to make a profound impact on the lives of people living with complex and/or chronic conditions, many of whom also face multiple barriers in their lives which makes it difficult for them to achieve the self-care required to improve their health and well-being. This position is currently hybrid but requires flexibility and may vary from day-to-day to meet members where they are. Outreach methods are based on the needs of the organization, and may include telephonic, or in person in a variety of potential settings such as but not limited to, the health center/practice, community, home, or an inpatient facility.

Responsibilities:
Conducts Comprehensive Clinical Assessments for both adult and pediatric members Assures that medication reconciliation is complete based on licensure. Nurse CMs will complete a medication reconciliation and may include a pharmacist and/or primary care BH Care Managers will refer all medication reconciliations to a Clinical Pharmacist 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 be required to meet members while they are inpatient to provide education and support about the discharge process and transition members into care management Travel throughout the assigned area to engage members at their homes or other locations where the member is located Assesses the members knowledge of their medical, behavioral health and/or social conditions and provides education and self-management support including symptom response plans based on the members needs and preferences Connects members with primary care, behavioral health, social services, Community Partner, respite, and other community-based services as indicated and appropriateIn collaboration with Community Health Workers, creates and maintains a comprehensive inventory of local community resources through a web-based application, improving accessibility for members and providers, and linking members with the appropriate support services
Participates in the integrated care team meetings and clinical rounds as required Maintain accurate, timely documentation in electronic systems including health center/practice EHRs Provides coverage for team members who are out of office Other duties as assigned

Required Skills:
3-5 years of nursing experience, in-home health, ambulatory care, community public health, case management OR 2-5 years of Inpatient or Community Social Work experience providing patient-centered outreach, behavioral health services, needs assessment and support Experience within the ACOs member population preferred including Medicare/Medicaid member populations Experience working with Federally Qualified Health Centers/ Primary Care Provider practices is strongly preferred Demonstrated success in working as part of a multi-disciplinary team including communicating and working with Providers, Pharmacists, Social Workers, Community Health Workers, and other health care teams Must demonstrate excellent interpersonal communication skills Ability to flexibly utilize clinical expertise to solve complex problems Experience working with patients with chronic and behavioral health needs Must be flexible and adaptable to change Demonstrate the ability to work independently Bi/multi-lingual preferred Additional qualities include enthusiasm and passion for helping people, genuine spirit, kind, and empathetic nature, and one who embraces a go with the flow mentality Experience using appropriate technology, such as computers, for work-based communication Experience and proficiency with Microsoft Office and online record keeping

Desired Other Skills:
Familiarity with the MassHealth ACO program Familiarity with Federally Qualified Health Centers Experience with anti-racism activities, and/or lived experience with racism is highly preferred

Qualifications:
RN/LPN with current, active MA nursing license OR Licensed Clinical Social Worker (LCSW or LICSW), or Licensed Mental Health Counselor (LMHC) A valid driver's license and provision of a working vehicle

** In compliance with Covid-19 Infection Control practices per Mass.gov recommendations, we require all employees to be vaccinated consistent with applicable law. **