Care Coordinator ESP

Harbor Health Services is an innovative, growing, mission-based organization that lives, serves and collaborates with our community members to achieve our mission to help individuals reach their full potential through access to local, affordable services that promote health. Harbor provides medical, behavioral health, dental, and support services to more than 34,000 patients in Boston, the South Shore, and Cape Cod. To help further the mission of Harbor, we are looking for a talented Care Coordinator to join our Care Team at the Elder Service Plan in Mattapan (Home base could also be in Brockton location)

Harbor Health operates two Elder Service Plan - Programs of All-Inclusive Care for the Elderly (PACE), a program that allows frail elders to live in their homes and communities.  Our Elder Service Plan has two medical and day centers in Mattapan and Brockton, MA and cares for more than 580 participants. 

Hours are Monday through Friday, 8:00 AM to 4:30 PM and is hybrid, after orientation/training, with minimum of 2 days on site at our Brockton location.

Harbor Health offers a GREAT benefits package including Health, Dental, Vision, Life, & Disability insurance, 403b Savings Plan, Generous Paid Time Off plus 11 additional Holidays and much more!

Role: 

The Care Coordinator is responsible for acting in a supportive role for the Interdisciplinary Team (IDT), focusing on the administrative functions that the Interdisciplinary team (MD's, NP's, Nursing, Social Workers, Nutritionists etc.)  must carry out to maintain compliance, improve quality patient care, and avoid hospital/emergency room utilization for our Elder Service Plan participants.  

Responsibilities:

• In collaboration with the Utilization Management RN, coordinates all phases of the admission or discharge of patients from the hospital or ER and communicates critical information to IDT to ensure appropriate care takes place.
• In collaboration with the Utilization Management RN, coordinates participant admissions/discharges to/from short term rehab or long-term care including making referrals to LTC facility, arranging transportation, and providing any necessary paperwork.
• Ensures specialty appointments have appropriate referral and authorization documented and coordinates follow up studies/appointments resulting from outside care.
• Responsible for documentation of all outside encounters (ED, Hospitalization, Nursing care) to support accurate fiscal performance analysis.
• Ensures all participants receive Care Plan and associated assessments every six months, utilizing reports and Electronic Health Record investigation to ensure CMS compliance.
• Prepares for and facilitates morning IDT meeting to include chart review, external record review and histories, service delivery requests, long term care tools, special team projects and takes disparate information, summarizes, and engages team to support real-time decision-making.
• Tightly manages follow up action items from meeting to ensure critical tasks are completed in a timely way.
• In collaboration with IDT, ensures new participant experience is seamless by coordinating multiple services are in place for first day in the program; ensures critical tasks are completed for patient safety and satisfaction.
• Facilitates critical clinical meetings involving IDT, outside facilities, vendors, and patients/caregivers, often requiring complex decision-making and conflicting opinions.
• Communicates with Home Care Manager and Rehab Manager regarding any support services as needs arise. 
• Coordinates multiple treatment providers for participants with multiple comorbidities and complex care needs.
• Serves as point of contact for IDT, participants, families/caregivers, nursing facilities and outside vendors.
• Serves as point person for IDT when out in field needing troubleshooting and/or information sharing between team members, serves as intermediary between Participant and Clinician, call screener and communicates detailed information to clinician. 
• Manages multiple responsibilities with frequent daily interruptions.  

Requirements: 

• Bachelor’s Degree in healthcare or related field
• May substitute clinical certification (CNA or Medical Assistant) with 4 years of related experience or Associates’ Degree in healthcare or related field with 2 years of experience, for the Bachelor’s degree
• One year of experience working in a health care environment performing care coordination, case management, medical office management or other related duties
• Experience working with an elderly population preferred
• Intermediate skill level with Microsoft Office 365 including Word, Outlook, Excel and Microsoft Teams
• Proven ability to resolve problems creatively
• Excellent verbal and written communication and organizational skills
• Ability to work independently and as a member of a Team
• Adept at time management, excellent multi-tasking skills, experience working with competing priorities, fielding & follow up of phone calls while maintaining focus throughout the day
• Ability to be flexible and creative as role grows and adapt to new changes
• Must be able to utilize critical thinking skills independently to problem solve complex situations.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.