The Care Coordinator will be based in the community and serve as a vital link connecting homeless individuals with serious mental illness, substance use disorders, and/or complex medical illnesses with needed care including mental health, substance use, and primary care as well as services that address social determinants of health needs. This work is part of a MassHealth initiative that provides qualified MassHealth enrollees with a service benefit called Behavioral Health Community Partners (BH CP). Victory Programs has partnered with Boston Healthcare for the Homeless and 8 other community-based providers to form the Social Determinants of Health BH CP Consortium to serve eligible MassHealth enrollees/patients/clients in the greater Boston area. The Care Coordinator will work as part of an interdisciplinary team across the city to take responsibility for coordinating the care for up to 50 enrollees. The Care Coordinator will work closely with other coordinators and nurse care managers to be responsible for engaging their clients regularly (several times a month), mostly face to face, and making sure that the client is getting connected to vital services and progressing towards the goals outlined in their Person-Centered Care Plan.

QUALIFICATIONS:

• A Bachelor’s degree in social work, human services, nursing, psychology, sociology, or related field; orAn Associate’s degree and at least one year professional experience in the field; orAt least three years of relevant professional experience.
• Experience in case management, human services, non-profit and or government agency is strongly preferred.
• Excellent customer service skills and the ability to communicate professionally with employees and clients both on the phone and in person
• Efficient, organized, resourceful, detail oriented, and able to complete tasks in time sensitive manner. Exceptional organizational skills.
• Self-directed with the ability to work both independently and interested in using data to help direct care
• Flexible, adaptable and able to multi-task
• Motivational Interviewing and Cultural Competency training a plus; experience working with homeless populations and/or populations with mental illness and substance use disorders.
• Proficient Computer skills especially with Microsoft Excel Spreadsheets.
• Must be able to embrace person-centered planning philosophy.
• Bilingual bicultural preferred
• Desire to improve services and the quality of life for persons marginalized by society.
• Ability to lift 5-10 pounds on a regular basis and 25-30 pounds occasionally
• Able to travel to different sites
• Able to stand for long periods of time
• Able to climb stairs
• Able to bend and stoop
• Current TB assessment and current CPR certification.
  Position Type: Full-time (40 hours) Monday - Friday daytime hours. On-site.
  Rate: $26.00/hr
  At Victory Programs, we value a diverse workforce and strive to create welcoming, inclusive, and accessible environments for our employees and the individuals accessing services. We are committed to sustaining healthy and functioning communities that respect and celebrate diverse experiences, identities, cultures, and ideas.
  For 50 years, Victory Programs has assisted individuals and families in crisis. Each year, thousands turn to us for shelter, sustenance, recovery, care, and compassionate professional support. Many of our clients struggle with homelessness, substance use, and mental health issues, and a significant number live with HIV/AIDS. Our dedicated team of over 350 staff members work across more than 25 programs to help people to develop and implement creative and safe solutions to the challenges they face.
  Our benefits program includes a 75% employer contribution to health insurance and a 25% employer contribution to dental insurance, as well as 100% employer-paid disability and life insurance and a 401K match. Victory Programs offers a generous paid time-off package to all employees, which includes vacation, sick leave, personal time, and holidays. Upon hiring, all staff members are entitled to up to 4 personal days, 160 hours of sick leave, 10 holidays, and 3.5 weeks of vacation. These figures may vary based on full-time or part-time status, and vacation time increases with length of employment

• Act in accordance with Victory Programs, Inc.’s Standards of Excellence at all times, including maintaining professional ethics, boundaries and client confidentiality.
• Assertively outreach and engage assigned individuals with the Behavioral Health Community Partner project
• Conduct timely Comprehensive Assessments
• Communicate and engage with clients regularly and help clients progress on goals identified in Patient Centered Care Plan
• Works with the nurse care managers assigned to the project
• Maintain weekly communication with the Behavioral Health Community Partner team via data sharing platform to improve coordination of information sharing/collaboration between clients and coordinators
• Documentation into data platform regarding enrollee progress on Care Plan goals, all client encounters & care coordination notes.
• Arranges or assists in arranging appointments for services needed and other related assessments including but not limited to those addressing the social determinants of health including housing, benefits, and legal affairs.
• Accompanies client to appointments as needed.
• Locates transient clients, when necessary, through community partners and or street outreach
• Triages and troubleshoots care need issues for clients
• Participates in team case conferences and advocates for clients’ needs
• Participates in community partnership trainings and learning collaboratives
• Ability to be self-motivated and proactive in reaching out to clients regarding multiple issues of concern including (but not limited to) housing services follow ups, medication adherence, legal assistance/coordination, wellness check-ins, and general ad hoc support.
• Works with Behavioral Health Community Partner team on the development and implementation of Patient Centered Care Plan
• Requests & sends medical records for care coordination purposes to providers, ACO, MCO as needed
• Work closely with all agency managers and other employees, ensuring a good working relationship with other departments.
• Complete reports of activities as required. Assist with compliance for data and reporting.
• Attend staff meetings and team meetings, in-service trainings and agency workshops,
• Participate and support the agency in program events, State House rallies, fundraising and advocacy events, HIV/AIDS rally and walk and any additional functions.
• Duties and responsibilities may be added, deleted or changed to meet program needs. .