The MCCN Care Coordinator will provide LTSS care coordination activities to youth and adult Enrollees of MCCN to facilitate the appropriate delivery of health care services and improve health outcomes. Such activities may include organizing care and facilitating communication across medical, behavioral health, LTSS, social, and pharmacy providers, agencies, and supports.

Essential Functions:

1. Work collaboratively and effectively with care management, including Assigned or Engaged Enrollee, medical team and other providers to provide LTSS care management services.
2. Work collaboratively with the care team to complete and utilize the Comprehensive Assessment results, and work with Assigned or Engaged Enrollee to develop or update the LTSS Care Plan within 122 days of assignment.
3. Ensure that the LTSS Care Plan meets the requirements of EOHHS and notify the care team if changes have occurred to Assigned or Engaged Enrollee’s functional status, including Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) needs, since the completion of the Comprehensive Assessment.
4. Ensure the Assigned or Engaged Enrollee receives necessary assistance and accommodations to prepare for, fully participate in, and to the extent preferred, direct the care planning process.
5. Ensure that the Assigned or Engaged Enrollee receives assistance in understanding LTSS terms and LTSS concepts, including but not limited to information on their functional status; how family members, social supports and other individuals of their choosing can be involved in the care planning process; self-directed care options and assistance available to self-direct care; and LTSS services or programs that are available to meet their needs and for which they are potentially eligible.
6. Inform the Assigned or Engaged Enrollee about his or her options for specific LTSS services and programs and providers that may meet their needs.
7. Assess the Assigned or Engaged Enrollee for social services and identify community and social services and resources that may support the health and wellbeing of the Assigned or Engaged Enrollee.
8. Conduct assessment for Flexible Services for all Assigned or Engaged Enrollees who are enrolled in an ACO. If Flexible Services are identified, make recommendation to ACO for approval.
9. Coordinate all aspects of service delivery and promote integration with health care providers, BH providers, LTSS providers and community/social service provides that the Assigned or Engaged Enrollee may be receiving, as outlined in the LTSS Care Plan.
10. Participate in Enrollee’s care team meetings to ensure effective communication among all disciplines 
involved in individual’s care.
11. Provide health and wellness coaching as directed by the Engaged Enrollee’s care team and as indicated in the Enrollee’s LTSS Care Plan.
12. Maintain regular contact with Assigned or Engaged Enrollee to monitor and coordinate LTSS Care Plan including quarterly face-to-face meetings.
13. Care Coordination activities include visiting locations in which the Enrollee is known to reside or visit; Conducting face-to-face home visits with the Enrollee on an initial and quarterly basis; complete in person follow up after discharge visit within 7 days following an Enrollee’s inpatient discharge, discharge from twenty-four (24) hour diversionary setting, or transition to a community setting.
14. Support transitions of care by completing a follow up within seven (7) calendar days following an Enrollee’s emergency department (ED) discharge. Coordinates clinical services and other supports for the Enrollee, as needed
15. Contacting the Enrollee’s providers and collaterals to ensure accurate contact information when Assigned or Engaged Enrollees become unreachable.

Other Functions:

16. Update the LTSS Care Plan periodically to reflect the Assigned or Engaged Enrollee’s changing needs.
17. Complete all required documentation in a timely manner.
18. Provide outreach services to individuals, as needed.
19. Responsible for obtaining any missing demographic information on assigned enrollees.
20. Provide transition planning and transition coordination to Engaged Enrollee including follow-up support post discharge.
21. Ensure that individuals receiving services are treated with dignity and respect in accordance with MCCN Human Rights Policy.
22. Perform all duties in accordance with the agency’s policies and procedures.
23. Strictly follow all agency Performance Standards.

Care Coordinator Qualification/Education/Experience:

1. 1. 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.
   2. 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.
   3. Experience in navigating individual and family service systems and demonstrated the capacity to work collaboratively and effectively with families and community-based colleagues.
   4. Ability to use Electronic Health Records (EHR) Systems to document and coordinate services.
   5. Must be able to perform each essential duty satisfactorily.
   6. 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.
   7. Strong organization skills with Attention to detail, multi-tasking skills, Prioritization skills, Analytical skills, Problem-solving skills, and Team skills.
   8. Strongly prefer that a candidate will have a demonstrated understanding of and competence of Health Equity and in serving culturally diverse populations.
   9. Commitment to MCCN values and mission.
   10. Ability to travel on a regular basis; Must have valid driver’s license and access to an automobile.
   11. Ability to read and speak English. Fluency in other languages, especially Spanish preferred.
   12. Strongly preferred experience in Microsoft Products and software i.e., Excel, Word, Outlook, etc.