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Clinical Social Worker Opening for Bay Cove Human Services

Job Summary:

The Clinical Care Partner acts as a liaison between the health insurer, Commonwealth Care Alliance, and Bay Cove staff. The Clinical Care Partner 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 care partner 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 people about CCA One Care program benefits, services and supports; coaches self-management skills as needed; and facilitates access to community services.

Essential Functions of Position:
The essential job duties/responsibilities of the position include but are not limited to the information listed below:

  • 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;
  • Conducts medication review and reconciliation.
  • Ensures timely information exchange, coordination and integration of care; 
  • Maintains quarterly contact with members, as indicated.

Requirements for the position:

  • MSW required (LISCW or LCSW preferred)
  • Experience working with people with psychiatric disability, co-occurring disorders and complex medical needs
  • Minimum of 2 years clinical and case management experienced preferred. 
  • Effective skills in managing, teaching, negotiating, and collaborating with multidisciplinary teams and member/family focus.  
  • 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 
  • Sensitivity to the cultural, religious, ethnic, disability and gender issues 
  • Skills and competence to establish supportive trusting relationships with members
  • 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
  • Ability to work in a professional and confidential capacity
  • Knowledge of personal computer applications and equipment
  • A COVID-19 vaccination is a requirement of the position.  One COVID-19 shot is acceptable, contingent on the individual receiving the second shot within the allotted time frame. 

Personal Characteristics:

  • Ability to work collaboratively as a member of multidisciplinary and cross-functional teams.
  • Ability to negotiate and resolve differences.
  • Ability to function under pressure in a fast paced human service environment.
  • 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 Salary: $60,000

Job Type: Full Time

Other Qualifications:

Driving is not a requirement. If you don’t have a car, you are expected to navigate public transportation independently.

Contact: Please contact Kathryn Whitaker at [email protected]