Complex Care Management Team Lead

Who we are:
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.

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.

Job Summary: Hours: In Person, Full Time, Monday- Friday, 8:30am-5:00pm Union: Yes Union Name: 1199SEIU Patient Facing: Yes

Complex care management (CCM) requires compassionate, dignified, and culturally appropriate interactions with patients who have long been disenfranchised, incorporating the social determinants of health, with the goal of breaking down the physical and systemic barriers that deter our patients from engaging in primary care and behavioral health services.

This Complex Care Management (CCM) Team Lead will provide care coordination for a panel of up to 25 high-risk primary care patients at a time. This individual will work closely with primary care teams and clinic-based case managers at Jean Yawkey Place, and will provide 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 activities based on patient needs.

Additionally, the Team Lead will provide operational and data support to the CCM Program Manager for approximately 50% of their time. This will include developing and leading some staff onboarding, identifying ongoing staff education needs, and operational coordination; and generating, analyzing, monitoring, and using routine data reports to inform daily operations, performance, and contract compliance for the CCM team.

Responsibilities:

Complex Care Coordination for High-Risk Patients

• Work in an assigned clinic at Jean Yawkey Place with a multidisciplinary team of providers, nurses, behavioral health clinicians, and case managers.
• Conduct outreach sessions as needed, with prior supervisor approval, to engage referred patients in the place where they frequent, receive care, and/or reside. 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 payor-determined timeframe.
• Document patient encounters, as well as all outreach attempts, in the electronic health record. Follow billing, documentation, and assessment guidelines as required by payors.
• Needs assessment: Complete intake and comprehensive needs assessment for assigned patients.
• Collaboratively develop and document progress towards patient-identified goals and plan of care.
• Coordinate services and assist patients with obtaining benefits, housing, housing tenancy supports, transportation, and other services that address their health-related social needs.
• 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.
• Develop and maintain awareness of community resources and services available to patients.
• Promote appointment adherence by assisting patients with scheduling medical and behavioral appointments as needed. Support referrals to SUD treatment programs as needed.
• Support during transitions of care: Provide coordination to patients during transitions of care; participate, as appropriate, in discharge planning with inpatient health care providers.
• 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.
• 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.
• Work with patients to complete MassHealth applications and redeterminations to avoid disruptions to coverage. Successfully complete the MassHealth Certified Application Counselor exam (CAC) within 60 days of hire and maintain active certification status.
• Participate in weekly case conference meetings to discuss mutual patients with care team members to maintain integrated care model.
• Participate in ongoing trainings on care management principles and practices.

Leadership in Complex Care Coordination

• Reporting: Manage CCM-related data reporting and monitor program metrics for the team. Develop plans with CCM Program Manager to help incentivize and manage performance for the team.
• Data transfer: Work with Accountable Care Organizations to facilitate timely and secure data exchange and transfer related to CCM contract requirements.
• Documentation: Assist CCM Program Manager with monitoring and managing timely and accurate tracking and documentation of enrollments, assignments, and dis-enrollments as needed.
• Staff support: Assist the CCM Program Manager to onboard, orient, train, and support new care coordinators. Provide mentorship and feedback to support care coordinator performance.
• Operational support: Support the CCM Program Manager in implementing policies, workflows, and operational supports that enable BHCHP to meet CCM-related quality benchmarks.
• Manage routine operations of the CCM Team when the CCM Program Manager is not present.

This role does not include direct supervision, hiring, or disciplinary responsibilities. Duties and responsibilities may be added, deleted, or changed to meet program needs, at the discretion of the Manager.

Qualifications:

• Requires at least three years of relevant professional experience, including experience with leading team operations in a health care setting
• 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.
• Experience with data analysis and reporting to support a variety of end users and organizational requirements combining clinical, financial, and operational data
• Ability to critically evaluate and assure data quality in reports and data sets
• Able to work with multidisciplinary team maintaining a good rapport with nursing staff, medical staff, other departments, and visitors
• Strong problem solving and communication skills (written and oral)
• Self-directed with the ability to work independently in multiple settings and consistently meet deadlines
• Knowledge of the network of services available to homeless persons, and experience working with homeless persons preferred
• Prior case management experience required
• Computer skills: proficient with Microsoft Word and Excel, as well as electronic health records
• Spanish or Haitian Creole language skills strongly preferred
• Valid driver’s license and car required or strongly recommended to travel to multiple outreach sites

Compensation and Benefits:

• The compensation increases based on years of experience and ranges from $23.80 - $38.08 hourly.
• 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.

Does this amazing opportunity interest you? Then we'd love to hear from you.

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.

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.

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.