Health Outreach Worker - Health Home (Part Time Position)

Bay Cove Human Services’ mission is to partner with people to overcome challenges and realize personal potential. Bay Cove pursues this mission by providing individualized and compassionate services to people facing the challenges associated with developmental disabilities, mental illness, substance use disorders, and homelessness at more than 175 program sites throughout Greater Boston and Southeastern Massachusetts. 

Bay Cove Human Services is committed to ensuring the representation and participation of candidates from diverse backgrounds and experiences. We encourage all qualified individuals, particularly those from historically marginalized groups, to apply.

Job Summary: 

The Health Outreach Worker (Part-Time) acts as a liaison between the health insurer, Commonwealth Care Alliance, and Bay Cove staff. The Health Outreach Worker coordinates all aspects of medical and psychiatric care for those receiving services from Bay Cove Human Services that are enrolled in CCA’s One Care Plan. The Health Outreach Worker coordinates and facilitates Interdisciplinary Care Team (ICT) meetings, participates in initial and annual assessments of each member; facilitates the development of an Integrated Care Plan (ICP) for each member; educates members about CCA One Care program benefits, services and supports, and resources in the community.

Essential Functions of the Position: 

• Conducts assessments of clinical health risk and needs, as well as of clients’ strengths

• Develops member directed care plans

• Facilitates the effective functioning of the Interdisciplinary Care Team (ICT), including coordinating meetings, facilitating communication and documentation;

• Collaborate closely with PCP and other Providers including, but not limited to community resources, and ensure appropriate referrals based on level of care needed to optimize outcomes and minimize risk;

• Effectively communicates any proposed changes in services, hospitalizations, medications, transitions of care, and crisis interventions

• Obtains required prior authorization from CCA;

• Provides coaching and support to clients as needed.

• Educates members about program benefits, services and community supports and services.

• Follows up within 48 hours of a member’s admission to an acute medical or psychiatric hospital, and coordinates with member and hospital staff to facilitate hospital discharges.

• Supports safe transitions for members moving between care settings, including but not limited to hospital to home, hospital to rehabilitation settings, rehabilitation settings to home, hospital to shelters, substance abuse treatment programs to community residence programs;

• Ensures timely information exchange, coordination and integration of care;

• Maintains quarterly contact with members, as indicated.

• Effective skills in managing, teaching, negotiating, and collaborating with multidisciplinary teams and member/family focus.

• Sensitivity to the cultural, religious, ethnic, disability and gender issues

• Skills and competence to establish supportive trusting relationships with members

• Ability to work in a professional and confidential capacity

• Ability to work collaboratively as a member of multidisciplinary and cross-functional teams.

• Ability to negotiate and resolve differences.

• Ability to be flexible, open and responsive to ongoing industry changes.

• Ability to articulate and communicate Bay Cove's mission and strategic direction in a consistent and enthusiastic manner.

• Ability to effectively represent the Agency in a variety of circumstances and forums.

• Ability to identify opportunities and obstacles and develop effective, creative solutions to pursue opportunities.

Job Requirements: 

• Minimum of 2 years case management experience preferred. Experience working with people with severe mental illness, substance use disorders, and complex medical needs.

• Bilingual preferred, not required.

• Strong time management, organizational, written, and oral communication skills.

• Familiarity with Electronic Medical records and electronic data collection systems.

• Knowledge of trauma-informed and culturally competent services

• Knowledge of empowerment and self-advocacy techniques

• Knowledge of available community health and mental health services and resources

• Knowledge of formal and informal assessment practices

• Driving is not a requirement, but ability to navigate and use public transportation is necessary. 

Bay Cove Human Services does not offer visa sponsorships at this time and will require candidates to be authorized to work in the United States.