Outreach Care Coordinator

$1,000 SIGN ON BONUS

We are looking for a full‑time Outreach Care Coordinator in our Long Term Services and Supports (LTSS) Community Partners (CP) program. The position is based at one site but services Fall River, New Bedford, Mashpee, and Brockton. The schedule is Monday through Friday, 8:00 a.m. – 5:00 p.m., and the budgeted starting salary is between $20.50 and $25 per hour.

• Respect the confidential nature of all program services and communications therewith.
• Conduct outreach to assigned enrollees to inform them about the functions of a CP Program, the role of the Care Coordinator, the optional nature of CP enrollment, choice in CP providers, the benefits of enrollment, and the enrollment process. Provide written documentation as warranted.
• Document all outreach attempts, which typically include a minimum of 3 phone call attempts, and additional strategies such as face‑to‑face attempts 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 members of the Participation Agreement and facilitate its sending to the enrollee.
• Facilitate warm hand‑off for completion of Comprehensive Assessment with ACO / MCO partners.
• Market the program to ACO / MCO Health Centers, hospitals, PCP offices and other entities, maintaining collaborative relationships with the same.
• Delegate assignments to part‑time Outreach Workers as applicable.
• Determine caseload assignments per geographic area on a monthly basis.
• Send No Contact, Disengagement, request for information, Intake Packet and other letters as required to members during absence of Intake Specialist.
• Complete disenrollment forms for members on the assigned caseload.
• Assist as Care Coordinator in gaps in coverage or growth areas in a geographic region.
• Obtain the Comprehensive Assessment from the referring ACO/MCO, integrate findings into the person‑centered Care Plan, and provide updates as needed for changes in functional status, ADL, or IADL needs.
• Ensure the LTSS Care Plan is approved by the Enrollee and the Primary Care Provider within required time frames and shared with all members of the care team.
• Facilitate enrollee’s access to needed services, including 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; provide ongoing monitoring of the implementation of the LTSS Care Plan; monitor for changes in status including health, housing, natural supports and caregivers; and 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.

• Strong written and oral communication skills and demonstrated computer skills.
• Bi‑lingual capacity in Spanish, Cape Verdean Creole, Haitian Creole, Portuguese strongly preferred.
• Minimum of a high school degree (or equivalent) and at least two years of experience, or an associate’s degree and at least one year of experience in the field; or a bachelor’s degree in social work, human services, nursing, psychology, sociology, or a related field.
• Will be based at one of the four sites and must be willing to travel to Fall River on a monthly basis for group supervisions and occasional trainings.

A comprehensive benefits package:

• Medical, dental, vision insurance
• Long‑term disability insurance
• Life insurance
• 403(b) pension plan
• Flexible spending account
• Three weeks paid vacation
• Twelve paid holidays
• Generous earned sick time

* Candidates must pass CORI and CPS (child protective services) background checks.*

*** Salaries are determined by factors including experience, education, certifications, references, and foreign language proficiency with clients.***

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 135‑year tradition of high quality.

Family Service Association is an Equal Opportunity Employer.