Clinical Care Outreach Worker

Overview

The Health Outreach Worker collaborates with the Clinical Care Manager (CCM) to provide care coordination for One Care enrollees with complex healthcare needs. The Health Outreach Worker collaborates with Vinfen’s CBFS teams and the One Care Plan’s clinical staff to maximize coordination and integration of care. The Health Outreach Worker also provides administrative support to the CCM.

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

• In collaboration with the Clinical Care Manger (CCM), provide outreach to and engagement of clients enrolled in One Care.
• Maintain and update all client documentation including health assessments and care plans in Vinfen’s systems and in the One Care Plan’s electronic medical record as applicable.
• With the CCM, facilitate the implementation and monitoring of the clients’ Individual Care Plans (ICP)
• Collaborate closely with CCM, PCP and including, but not limited to other healthcare providers and community resources, and facilitate appropriate referrals based on level of care needed to optimize outcomes and minimize risk.
• Collaborate with CCM, One Care Plan, PCP and other health care providers regarding changes in services, care transitions, crisis intervention;
• Under the supervision of the CCM, conduct home and community-based visits as required
• Provide support and education to clients to enhance health and wellness self management.
• Assist participants in accessing health care services, through training or by directly accompanying or transporting them to health care visits as requested by the CCM
• Serve as a resource for clients, families, and outside agencies requesting information.
• Maintain appropriate written and oral communication.
• Participate in quality assessment and quality improvement within the scope of responsibilities including data collection, reporting, analyses, and quality management activities designed to improve care and increase effectiveness of the service model.
• Actively participate in the evaluation of own performance.
• Seek to maintain a constructive work environment and maintain effective communication with others.
• Maintain confidentiality of client and employee information.
• Travel to meet with One Care clients either in the community or in Vinfen locations, as needed.
• Perform other related duties, as required.

Knowledge and

Skills:

• Excellent organizational, time management, and problem solving skills
• Ability to function effectively as part of a multi-disciplinary team
• Knowledge regarding psychiatric rehabilitation and recovery
• Effective oral and written skills
• Strong interpersonal and customer relations skills
• Effective teaching skills
• Knowledge of business communication formats (correspondence, memos, minutes, reports, financials, etc.)
• Knowledge of business etiquette and practices
• Knowledge of grammar and punctuation
• Ability to compose routine correspondence
• Specific knowledge of:
  Microsoft Office, including Word, Excel, and Access, Outlook Vinfen’s internet access applications
• Department-specific applications
• Knowledge of recordkeeping systems
• Organization and quantitative skills Repeated from above
• Ability to communicate in a positive, courteous, and professional manner
• Ability to exercise judgment & discretion in dealing with individuals and confidential matters
• Knowledge of Vinfen’s mission, organization, and services

Established in 1977, Vinfen is a nonprofit, health and human services organization and a leading provider of community-based services to individuals with mental health conditions, intellectual and developmental disabilities, brain injuries, and behavioral health challenges. Our services and advocacy promote the recovery, resiliency, habilitation, and self-determination of the people we serve. Vinfen's 3,500 dedicated employees are experienced, highly-trained professionals who provide a full range of supportive living, health, educational, and clinical services in over 550 sites throughout Massachusetts and Connecticut.

For more information about Vinfen, please visitwww.vinfen.org/careers.

My Job. My Community. My Vinfen.

Vinfen is an Equal Opportunity…