Title: Social Work Care Manager, BH TOC
Reports to: Manager, Behavioral Health Transitions of Care Program
Classification: Individual Contributor
Location: Western Massachusetts area (Franklin, Hampshire and Hamden counites)
Job description revision number and date: 7.17.24

Organization Summary:

Community Care Cooperative (C3) is a 501(c)(3) non-profit, Accountable Care Organization (ACO) governed by Federally Qualified Health Centers (FQHCs). Our mission is to leverage the collective strengths of FQHCs to improve the health and wellness of the people we serve. We are a fast-growing organization founded in 2016 with 9 health centers and now serving hundreds of thousands of beneficiaries who receive primary care at health centers and independent practices across Massachusetts. We are an innovative organization developing new partnerships and programs to improve the health of members and communities, and to strengthen our health center partners.

Job Summary:

The Social Worker with the Transitions of Care team (TOC) will have the opportunity to make a profound impact on the lives of people living with complex mental health, behavioral, and substance abuse needs. The Social Worker will serve as a critical member of the integrated care team, which is made up of community health workers, pharmacists, FQHC staff, and program coordinators. They must be prepared to work from home office, hospital, Health Center, providers office setting, within patients homes, or in the community.

Responsibilities:

Engages members and caregivers in active care planning to focus on behavioral, social, and environmental concerns and needs
Collaborates with members, caregivers, and inpatient social workers on discharge planning to ensure improved access to care, increase community tenure, and decrease visits to the ED and the risk of psychiatric readmissions
Maintain an on-site presence at assigned hospitals and develop relationships with members clinical teams
Assesses the members knowledge of their behavioral health conditions and provides education and self-management support based on the members preferences
Connects members with primary care, behavioral health, and other services as needed
Establishes relationships with community agencies, resources, and supports that are relevant to the Medicaid population
Meets members while admitted to an inpatient psychiatric unit to provide education about BH TOC support
Completes comprehensive post-discharge assessments and patient-centered care plans
Facilitates medication reconciliation with pharmacist
Travels to engage members at their homes or in the community
Measures, improves, and maintains quality outcomes (clinical, financial, and functional) for individual members and the population served
Maintains accurate and timely documentation in electronic systems
Provides team support as needed

Required Skills:

Demonstrated success in working as part of a multi-disciplinary team including communicating and working with providers, nurses, and Community Health Workers
Skilled in Motivational Interviewing, patient engagement strategies, Risk Assessments, and case management
Experience in working with members with mental illness and/or substance misuse disorders
Ability to flexibly utilize clinical expertise to solve complex problems
Proven ability to work independently
Proven ability to prioritize and flexibly manage a variable workload
Excellent interpersonal communication skills and an ability to engage with varying patient populations
Experience and proficiency with Microsoft Office suite and online record keeping
Excellent organizational and time management skills
Skilled at advocating for patients within the medical, psychiatric, and community settings
Personal and professional commitment to best-practice patient care
Desired Other Skills:
Familiarity with the MassHealth ACO program
Familiarity with Federally Qualified Health Centers
Experience with anti-racism activities, and/or lived experience with racism is highly preferred
Bi-lingual (preferred)
Additional qualities that would be a good fit for our team include enthusiasm and passion for helping patients, genuine spirit, kind and empathetic nature

Qualifications:

2-3 years of Inpatient or Community Social Work experience providing patient-centered outreach, behavioral health services, needs assessment, and support
Master of Social Work or Master's in Counseling
Current, active MA LCSW, LICSW or LMHC licensure
A valid driver's license and provision of a working vehicle
** In compliance with Covid-19 Infection Control practices per Mass.gov recommendations, we require all employees to be vaccinated consistent with applicable law. **