Job Details: HOW Mobile Care Partner

Commonwealth Care Alliance Charlestown, MA

About the Job

Job Details: HOW Mobile Care Partner On-Line Application + + + + Vacancy NoVN1835 Posting TitleHOW Mobile Care Partner Location CityCharlestown Language Requirement Job Description ORGANIZATION OVERVIEW: Commonwealth Care Alliance is a rapidly growing nonprofit organization providing integrated health care and social support services to people with complex medical needs. Our patients are seniors and persons with disabilities covered under Medicaid or both Medicaid and Medicare. Our innovative care model is nationally recognized for its effectiveness in improving health outcomes for these vulnerable populations. Our unique care model is empowering for our employees as well as our members. Whether you are a clinical or administrative professional, all of us at Commonwealth Care Alliance receive the satisfaction of knowing our work truly makes a difference. We enjoy a company culture of passionate advocacy in a supportive work environment with opportunities for growth and learning, competitive salaries, and a generous and comprehensive benefit package. Commonwealth Care Alliance’s (CCA) Care Partner Team is primarily responsible for providing longitudinal care coordination, care management, and/or care delivery to a dedicated panel of dually-eligible CCA members, a group of individuals with significant medical, behavioral, and social complexities that require intensive clinical support. TheHealth Outreach Worker (HOW), Care Partner (Mobile)assists members in managing their overall goals in their home. The HOW, Care Partner (Mobile) manages a panel of geographically co-located members. The HOW, Care Partner (Mobile) works in collaboration with a CCA primary care team to improve member care through the promotion, prevention, and reduction of health risk. The HOW, Care Partner (Mobile) functions as an advocate and coach for members who require additional support to meaningfully address social, psychological, and medical needs which they have outlined as goals in their care plan. They may provide information on available resources, provide social support and informal counseling, advocate for individuals and community health needs and may assist in collecting data to help identify community health problems. The HOW, Care Partner (Mobile) reports to the Care Partner Team Lead. THIS POSITION WILL VISIT MEMBERS IN BOSTON AND METRO BOSTON AREA Key Responsibilities: • Identifies and refers for action, members of the Interdisciplinary Site Team (IST) and oversees completion of those interventions, and collaborates on successful outcomes. • Manages an assigned panel of members longitudinally, based on the assessment and plan of care and need stratification determined. • Conveys the purpose of the program to the member and member’s care giver. • As indicated, supports, provides education or identifies resources within the IST to provide needed interventions to members in health maintenance, such as: exercise, nutrition, health care system navigation, substance use, and other health behaviors primarily in the home setting. • Addresses issues regarding substance misuse/abuse and, if indicated, discusses concerns with the IST team or deploys support resources within the IST. • Uses recovery strategies such as motivational interviewing, harm reduction, positive behavioral support techniques, limit setting and strength based approaches to support members in attaining stated goals. • Provides support and notifies clinical team and program manager, regarding changes in: behavior, nutrition, exercise, substance use, medication compliance, and other issues as related to the established care plans. • Assists members in utilizing resources, including scheduling appointments, transportation and accompaniment, and assists with completion of applications for programs for which they may be eligible. • Assists with housing issues, applications and referrals. • Continuously expands knowledge and understanding of health related issues/diagnosis, community resources, services and programs available and effectively works with individuals from diverse backgrounds in reducing cultural and socio-economic barriers. • Provides 1:1 education to members regarding chronic disease self-management to prevent and manage health conditions and that encourages healthy behaviors and supports members in developing healthier habits. • Provides medication management education and support to members in the home setting including reminding and observing the member with medication self-administration including completing all appropriate documentation. • Documents all activities; service plans, and results using an Electronic Medical Record, in an effective manner while strictly adhering to the policies and procedures in place. • Maintains appropriate written and oral communication on a timely basis, completing documentation within 24 hours of activity, and returning non-urgent calls within 48 hours Minimum Education required:Associate's Degree or equivalent experience Preferred Educational Experience:Bachelor's Degree Minimum Years’ Experience required:3 years Minimum Experience: • 3 years working in outreach or in the community, with members who have high behavioral health needs and high medical complexity. • CHW Certified Knowledge, Skills and Abilities Required: • Ability to use SBAR Communication • Ability to utilize an Electronic Medical Record • Ability to use on-line training platforms • Demonstrated understanding of the Model of Care • Demonstrated understanding of the benefits of each program • Ability to review welcome packets and obtain consent forms and attach them to EMR • Demonstrated understanding of when an updated MDS is needed • Ability to complete and update a Care Plan that meets CCA requirements • Demonstrated understanding of LTSS • Demonstrated understanding of how to use CDSTs when ordering services • Ability to create referrals and authorize services within appropriate time frames • Ability to complete and lock all required telephone encounters within 48 hours • Demonstrated knowledge and ability to use depression screening/ assessment tools (e.g., PHQ 2, PHQ 9) • Demonstrated understanding of Referral to Specialists Preferred: • Demonstrated understanding of, and can apply, member stratification • Demonstrated understanding of how Minimum Data Set (MDS) supports stratification Working Conditions: • Must be willing and able to travel to member’s homes in addition to working in an office environment occasionally • Valid driver’s license with no restrictions. Ability to be active and mobile across Massachusetts Equipment Utilized • Standard office equipment • Experience with electronic medical record strongly preferred (eCW a plus) Language Requirement(s) English required, bilingual preferred Please note employment with CCA is contingent upon acceptable professional references, a background check (including Mass CORI, employment, education, criminal check, and driving record, (if applicable)), an OIG Report and verification of a valid MA/RN license (if applicable). Commonwealth Care Alliance is an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state or local laws. CCA is committed to protecting the health of our workforce and our members, and we encourage flu vaccination in accordance with CDC recommendations. Individuals working in clinical care areas or in direct contact with members must provide documentation of flu vaccination, or wear a mask during flu season whenever engaged in member-facing activities.