Care Coordinator

Bay Cove Human Services; Somerville (MA); On-site; USD 46,000 - 48,000; Full time

Job summary

Bay Cove Human Services in Somerville, MA seeks a Care Coordinator to help residents access and coordinate medical, behavioral health, and substance use services, including MAT, insurance, and aftercare planning. The role emphasizes partnership with residents and coordinating care across disciplines.

The position involves triage to prevent gaps in care, discharge planning, and collaboration with a multidisciplinary team to monitor progress and maintain documentation.

Qualifications

• Coordinate medical, behavioral health, and substance use services for residents.
• Maintain relationships with providers and family members as needed.
• Document services and referrals in compliance with agency requirements.

Responsibilities

• Maintain partnerships and an updated database of community resources and services.
• Serve as the primary point of contact for resident care planning and support.
• Connect residents with substance use, mental health, healthcare, and community resources.
• Coordinate medical, behavioral health, MAT, and psychiatric care for residents.
• Prevent gaps in care through triage, facilitating access, treatment coordination, and follow-up.
• Assist residents with insurance, appointments, transportation, and healthcare access.
• Coordinate communication among providers, counselors, agencies, courts, and healthcare partners.
• Support discharge planning, aftercare development, and post-discharge follow-up.
• Collaborate with multidisciplinary teams to monitor progress and adjust treatment plans.
• Document services, referrals, and resident records in compliance with agency requirements.
• Provide crisis prevention and intervention, escalating to the appropriate party when needed.

Skills

Care coordination

Multidisciplinary teamwork

Crisis intervention

Communication skills

Job description

Bay Cove Human Services’ mission is to partner with people to overcome challenges and realize personal potential. Bay Cove pursues this mission by providing individualized and compassionate services to people facing the challenges associated with developmental disabilities, mental illness, substance use disorders, and homelessness at more than 175 program sites throughout Greater Boston and Southeastern Massachusetts. Department/Program: Residential Recovery Services Reports to: Clinical Director Supervisory Responsibilities: None Schedule: Monday-Friday 9am-5pm Job Summary: The Care Coordinator helps residents access and coordinate medical, mental health, and substance use services, including insurance, MAT, psychiatric care, and aftercare planning. The Care Coordinator contributes to Bay Cove’s mission by partnering with residents to support their recovery and overall well-being. This is a non-exempt position. Essential Functions of Position: Maintain partnerships and an updated database of community resources and services. Serve as the primary point of contact for resident care planning and support. Connect residents with substance use, mental health, healthcare, and community resources. Coordinate medical, behavioral health, Medication for Addiction Treatment (MAT), and psychiatric care for residents. Prevent gaps in care through triage, facilitating access, treatment coordination, and follow-up. Assist residents with insurance, appointments, transportation, and healthcare access. Coordinate communication among providers, counselors, agencies, courts, and healthcare partners. Support discharge planning, aftercare development, and post-discharge follow-up. Collaborate with multidisciplinary teams to monitor progress and adjust treatment plans. Document services, referrals, and resident records in compliance with agency requirements. Provide crisis prevention and intervention, escalating to the appropriate party when assistance is needed (supervisor, AMCI Team, etc.). Other job-related activities as assigned. All BSAS licensed programs must have at least one staff member designated to serve as coordinator for the following topics. If assigned, both supervisor and employee must initial to acknowledge the assignment: Serve as the program’s Access/CLAS Coordinator. Support the team in the evaluation, improvement planning, and implementation of efforts to ensure equitable access to services as required by 105 CMR 164.040(A)(11). Attend CLAS training. Serve as the program’s HIV/AIDS/HEP C Coordinator. Oversee resident and staff education, risk assessment, access to counseling and testing, and standards of care. Attend PACNET meetings and relevant Bureau of Infectious Disease meetings, conferences and trainings. Serve as the program’s Tobacco Education Coordinator (TEC). Oversees implementation of BSAS guidelines for integrating tobacco assessment, education, and treatment. Attend TEC meetings and trainings. Serve as the program’s Human Rights Coordinator (HRC). Provides staff and residents with training on resident rights and grievance processes and serves as liaison to the agency’s human rights department. Personal Characteristics: Utilizes a flexible and responsible work style that meets evolving needs of the agency. Works with integrity and respects the dignity and value of all individuals. Exhibits mission through job knowledge, pride in work role, and advocacy. Promotes diversity and inclusion of all individuals. Works in a collaborative, compassionate manner with stakeholder/ partners. Physical Requirements: Ability to enter and navigate various physical environments, including multi-story buildings without the use of an elevator. Ability to use a computer, tablet, and mobile phone for data entry, communication, and record-keeping. Ability to remain in a stationary position (e.g., sitting at a desk or in meetings) for extended periods while completing documentation and administrative tasks. Frequent movement throughout the program to conduct wellness/safety checks, check the physical environment, and move supplies. Frequent and clear communication with individuals, colleagues, and partners, requiring the ability to exchange accurate information in person, by phone, and in writing. Occasional lifting or carrying of program materials, supplies, or small equipment (up to 20 pounds). Ability to provide Cardiopulmonary Resuscitation (CPR) and overdose rescue (naloxone administration) if needed. Pay Rate: $22.44 hourly