Clinical Care Coordinator

Pittsfield, MA

General Description

The Clinical Care Coordinator under the direction of the Program Director, Assistant Program Directors, Clinical Care Manager and/or Nurse Care Manager will provide outreach, engagement, assessment, and person centered treatment planning for individuals engaged and enrolled in the Brien Center’s Behavioral Health community Partner (BHCP) Program. The Clinical Care Coordinator provides specialized care coordination and care management services to Enrollees. The Clinical Care Coordinator engages one on one with the Enrollee to integrate and coordinate care, support care transitions and support delivery of treatment for Enrollees with Serious Mental Illness, C-occurring disorders, and Substance Use Disorders in collaboration with the Interdisciplinary Team and BHCP staff.

Essential Job Functions

  • Under direction of the Program Director, support outreach and engagement efforts to Enrollees to provide information about the BHCP program.
  • Assist in gathering data to support the assessment process.
  • In collaboration with the BHCP Nurse Manager, Clinical Care Coordinator and BHCP staff, identify cultural and linguistic needs and preferences and deliver person-centered care based on those needs.
  • Provide community based BHCP services to Enrollees with Serious Mental Illness (SMI) and Co-occurring disorders and collaborate with the care team and staff that have expertize in SMI.
  • Continuously identify and resolve barriers to meeting goals complying with the Person-Centered Treatment Plan and report such barriers identified to the assigned care coordinator.
  • Support the Enrollee in goal achievement by scheduling follow-up contacts as needed and appropriate. Assess progress against the care plan goals and modify as needed.
  • Facilitate referrals to care, transportation and other supports to ensure that Enrollees attend appointments. Assist with transportation to needed appointments as necessary
  • Assist Enrollee in navigating the network of community based services and information.
  • Support safe transitions of care for Enrollees moving between care settings and services.
  • Facilitate communication between Enrollee or designated representative and medical, behavioral, and social service providers.
  • Attend meetings as required or requested.
  • Participate in supervision with supervisor as required.
  • Complete all required documentation in a timely and accurate manner.
  • Participate in trainings as required.
  • Assist with making reminder phone calls for appointments.
  • Other duties as assigned by Clinical Care Manager, Program Director, and Assistant Program Directors.
  • Facilitate clinical groups regarding anxiety, substance use, and other clinical areas of need.
  • Act as a Lead Coordinator and provide support and guidance to Care Coordinators as needed.
  • Model Person Centered Care and help train Care Coordinators on Person Centered Treatment plans and interventions.
  • Represent the team at ACO meetings as assigned.

Qualifications

  • Masters Degree in social work, psychology, counseling or other clinical concentration required.
  • Experience in community-based behavioral health support programs preferred.
  • Experience with accessing local resources, navigating health, behavioral health and/or substance use treatment systems preferred.
  • Valid driver’s license with reliable transportation and appropriately insured vehicle required.
  • Knowledge of Substance Use Disorder treatment paths including medication assisted treatment options, community resources, and knowledge of 12 Step recovery model.
  • Willingness to perceive substance use treatment and recovery through the lens of chronic disease management and holistic care.     
  • Ability to work on an interdisciplinary team
  • Experience providing person-centered care coordination and care management to adults with mental illness and substance use disorders

Skills

  • Ability to work with a wide variety of people and personalities.
  • Ability to conduct themselves professionally and represent the agency in a professional manner.
  • High regard for confidentiality and the handling of confidential information.
  • Excellent customer service and communication skills.
  • Strong motivational interviewing skills.
  • Excellent communication, documentation, time management, and organizational skills.
  • Leadership talent
  • Proficient computer skills.

Other Requirements

  • Driver’s license check (RMV)
  • Criminal Offender Record Information Check (CORI)