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Job Position

Care Coordinator

Care Coordinator 

Job ID: #587
Program: Coordinated Care Network 
Location: Fall River, MA

SUMMARY: The Care Coordinator works as an integral part of the Program Team. The Care Coordinator will perform, but not limited to the following duties: collaboration and continuous partnership with chronically ill or “high risk” enrollees and their family/caregiver(s), clinic/hospital/specialty provider, staff, and community resources in a team approach. This position requires a flexible schedule including 1st and 2nd shift. The agency has the right to change shifts based on the needs of the organization.

  • Serve as a contact point, advocate, and informational resource for enrollees, care team, family/caregiver(s), payers and community resources.
  • Work with consumers to plan and monitor care: assess consumer’s unmet health and social needs.
  • Develop a care plan with the consumer, family/caregiver(s) and providers (emergency plan, health management plan, medical summary, and ongoing action plan as appropriate).
  • Monitor adherence to care plans, evaluate effectiveness, monitor consumer progress in a timely manner, and facilitate changes as needed, create ongoing processes for consumer and family caregiver(s) to determine and request the level of care coordination to support their desire at any given point in time.
  • Facilitate consumer’s access to appropriate medical and specialty providers.
  • Educate consumers and family/caregiver(s) about relevant community resources.
  • Facilitate and attend meetings between consumer, family/caregiver(s), care team, payers and community resources as needed.
  • Cultivate and support primary care and specialty provider co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals.
  • Assist with identification of “high risk” enrollees (the chronically ill and those with special health care needs), and flag in the EMR.
  • Provide feedback for the improvement of care coordination.
  • Ability to climb three flights of stairs to deal with emergencies.
  • Ability to respond to emergency situations by placing calls to Fire, Rescue, Police and Medical, etc.

The Care Coordinator must perform each essential function satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions. The qualifications listed below are representative of the knowledge/skill and/or ability required.

  • Bachelor’s degree in human services field preferred.
  • Minimum two years’ experience working with mental health/substance use disorders.
  • Local knowledge about and connection to community health care and social welfare resources desirable.
  • Superior attention to detail, organizational skills, communication skills, and multi-tasking skills.
  • Good working knowledge of computers, electronic health records and data collection.
  • Requires valid driver’s license due to business-related travel.
Steppingstone Incorporated is a United Way Agency