Outreach Care Coordinator

• Respect the confidential nature of all program services and communications therewith.
• Conduct outreach to assigned enrollees to inform about the functions of a CP Program, role of the Care Coordinator, the optional nature of CP enrollment, choice in CP providers, the benefits of enrollment and the process for enrolling. Provide written documentation to members as warranted. 
• Document all outreach attempts which typically include a minimum of 3 phone call attempts; and additional strategies including face-to-face attempts if warranted, and other correspondence.
• Make contact with members during outreach to complete Follow Up after Discharge summary as needed.
• Schedule Intake appointments for Care Coordinators as appropriate.
• Complete Risk Assessment as required. 
• Inform potential member of Participation Agreement and facilitate sending it to the enrollee. 
• Facilitate warm hand-off for completion of Comprehensive Assessment with ACO / MCO partners. 
• Responsible for marketing program to ACO / MCO Health Centers, hospitals, PCP offices and other entities including maintaining collaborative relationships with same.
• Responsible to delegate assignments to part-time Outreach Worker as applicable
• Determination of caseload assignments per geographic area on a monthly basis.
• Complete No Contact, Disengagement, request for information, Intake Packet and other letters as required to send to members during absence of Intake Specialist. 
• Completion of disenrollment forms for members on assigned caseload.  
• Assignment as Care Coordinator to assist in gaps in coverage as needed, or in growing area of need in a geographical region, including but not limited to the following duties and responsibilities.
• Obtain the Comprehensive Assessment from the referring ACO/MCO, integrate findings into person-centered Care Plan and provide update as needed for any changes in functional status, ADL, or IADL needs. 
• Ensure LTSS Care Plan is approved by the Enrollee and the Primary Care Provider within required time frames. Ensure Care Plan is shared with all members of the care team. 
• Facilitate enrollee’s access to needed services, including but not limited to, Flexible Services, ACO/MCO chronic disease management programs, LTSS and other Community Resources.
• Maintain regular contact with the enrollee to monitor and promote progress toward Care Plan goals; to assist the enrollee to navigate and access needed services: to provide ongoing monitoring of the implementation of the LTSS Care Plan; to monitor for changes in status including health, housing, natural supports and caregivers and to provide health and wellness coaching with a minimum of one face-to-face contact quarterly.     
• Maintain all documentation required for the delivery of LTSS Community Partners services.

• Preferred Area of Educational Emphasis: Human Services Bachelors Degree Preferred
• Experience Required:  Three years of experience in a related capacity required with High School/GED, 1 year of relevant experience with Associates Degree, and relevant experience preferred with Bachelors Degree
• Must have strong written and oral communication skills and demonstrated computer skills
• Experience Desired:  Prior experience in marketing, customer service or outreach / engagement preferred. Bi-lingual language capacity in Spanish, Cape Verdean Creole, Haitian Creole, Portuguese desired.     

Family Service Association is a comprehensive private, non-profit social service agency dedicated to the development and implementation of services designed to provide strength and support to individuals and families throughout southeastern Massachusetts.  Headquartered in Fall River, Family Service Association strives to increase the capacity of individuals and families to cope with the stresses of family life and interpersonal relationships in a positive, productive and health-improving manner.  This agency is a leading provider of professional social services in the South Coast region of Massachusetts, with a 130-year tradition of high quality.