Care Coordinator - Street Team

bhchpjobs; Boston (MA); On-site; USD 30,651 - 49,042; Full time

Benefits offered by this job

Health, dental, vision insurance

403B retirement plan

Pre‑tax MBTA pass program 40% discount

Bi‑lingual proficiency premium

Job summary

Boston Health Care for the Homeless Program is seeking a full‑time Care Coordinator to join a multidisciplinary primary care team. You will work with unsheltered individuals, providing urgent and ongoing medical and behavioral health care in streets and community locations.

The ideal candidate is compassionate, flexible, and self‑motivated with a strong commitment to serving vulnerable populations. You will walk 5+ miles daily and coordinate with housing partners to address social determinants

Qualifications

• Experience working with vulnerable populations, including people with trauma, homelessness, or substance use disorders.
• Strong interpersonal skills and case management problem‑solving.
• Efficient, organized, detail‑oriented, and able to complete tasks in a time‑sensitive manner.
• Self‑directed with the ability to work independently and with clinical staff on shared patient goals.
• Commitment to working with underserved populations.
• Ability to travel regularly between outreach locations and access community sites.
• Ability to use standard office and field technology for documentation and communication.

Responsibilities

• Provide outreach‑based care coordination and non‑judgmental support with Street Team members.
• Engage individuals with substance use disorders and mental health conditions using trauma‑informed care.
• Conduct health and needs assessments and develop integrated care plans with the primary care team.
• Assess social determinants of health and support patients based on goals and priorities.
• Coordinate with outreach and housing partners to address social determinants of health.
• Track appointments, referrals, and primary care; follow up to support adherence.
• Conduct street outreach and home visits as needed.
• Represent Street Team at housing meetings with City of Boston and partners.
• Coordinate monthly meetings with housing partners for current patients.
• Complete MassHealth CAC exam within 60 days of hire and maintain certification.

Education

Bachelor’s degree preferred

Job description

Who we are:

Since 1985, BHCHP’s mission has been to ensure unconditionally equitable and dignified access to the highest quality health care for all individuals and families experiencing homelessness in greater Boston. Over 10,000 homeless individuals are cared for by Boston Health Care for the Homeless Program each year. We are committed to ensuring that every one of these individuals has access to comprehensive health care, from preventative dental care to cancer treatment. Our clinicians, case managers, and behavioral health professionals work in more than 30 locations to serve some of our community’s most vulnerable—and most resilient—citizens.

From our earliest days as a program, we have always sought to do work that is transformational: recognizing our shared humanity; centering dignity, compassion, mutual respect and supporting the right of every individual to access the highest levels of health care and every staff member to reach their fullest potential. We continue to be committed to building bridges and breaking down barriers, including systemic racism which harms us all. We provide community-based health care services that are compassionate, dignified, and culturally appropriate, incorporating social determinants of health, with the goal of breaking down the physical and systemic barriers that our patients face.

Our dedicated clinical and non‑clinical staff work hard to bring the mission alive. The central focus of that mission is the care of those individuals who avoid shelters and sleep on the streets. This population suffers very high mortality rates and presents a complex burden of co‑occurring medical, mental health and addiction problems that place them at great risk. Living throughout the year on our city’s streets, this group is exposed to the extremes of violence and weather and are among the highest users of emergency medical services.

Job Summary:

Hours: Full‑time, Monday‑Friday; 08:30am – 5:00pm
Union: Yes (1199 SEIU)
Patient Facing: Yes

Boston Health Care for the Homeless Program Street Team is seeking a full‑time Care Coordinator to join our multidisciplinary team. In this role, you’ll work with an integrated and multidisciplinary primary care team that seeks out the men and women of our city who live unsheltered, offering both urgent and ongoing medical and behavioral health care. The ideal candidate is flexible, compassionate, and self‑motivated with a strong commitment to serving vulnerable populations. This role requires delivering low‑threshold, high‑quality care coordination in nontraditional settings such as streets, encampments, and community locations. Because you’ll be practicing on the streets, you can walk more than five miles a day in varying weather conditions.

The Care Coordinator will be responsible for providing case management and care coordination for a panel of adults with a history of chronic unsheltered homelessness, including a subset of high‑risk patients enrolled in the Behavioral Health Community Partners Program. This work includes completing required assessments and documentation based on insurance and program requirements, while working closely with the Street Team to address barriers to health care with a strong focus on social determinants of health.

Responsibilities:

• Provide outreach‑based care coordination and non‑judgmental support in collaboration with other Street Team members
• Engage individuals experiencing substance use disorders and mental health conditions using low threshold principals and trauma‑informed care practices
• Conduct health and needs assessments and collaborate with patients and the primary care team to develop and implement integrated care plans
• Assess social determinants of health (e.g., housing, food access, benefits, transportation) and support patients in addressing these needs based on their goals and priorities
• Coordinate as needed with outreach and housing partners to address social determinants of health for shared patients
• Track patient appointments, referrals, and primary care; follow up with patients to support appointment adherence or rescheduling when appointments are missed
• Conduct street outreach and home visits with Street Team as necessary
• Represent the Street Team at housing‑related meetings with the City of Boston and other partner agencies regarding unsheltered patients empaneled to the Street Team
• Coordinate and facilitate monthly meetings with housing partners regarding patients currently housed and empaneled to the Street Team
• Successfully complete the MassHealth Certified Application Counselor exam (CAC) within 60 days of hire and maintain active certification status

Qualifications:

• Experience working with vulnerable populations, including people with a history of trauma, those experiencing socioeconomic stress, homelessness, mental health challenges, or substance use disorders
• Strong interpersonal skills and case management problem‑solving
• Efficient, organized, detail‑oriented, and able to complete tasks in a time‑sensitive manner
• Self‑directed with the ability to work both independently and collaboratively with clinical staff on shared patient goals
• Bachelor’s degree preferred but not required
• Demonstrated commitment to working with underserved and vulnerable populations
• Ability to work collaboratively as part of a multidisciplinary healthcare team using a coordinated, patient‑centered approach
• Ability to manage a fast‑paced workload, prioritize tasks, and maintain professionalism in stressful or unpredictable situations
• Self‑motivated with the ability to work both independently and collaboratively with team members across multiple locations
• Ability to travel regularly between outreach locations and access community sites
• Ability to use standard office and field technology, including computers, tablets, and telephones, for documentation and communication
• Ability to lift and carry 5–10 pounds regularly and up to 15–20 pounds occasionally
• Ability to climb stairs, bend, stoop, and navigate uneven terrain commonly encountered during community and street outreach
• Ability to walk 5+ miles/day in all weather conditions—you will do street outreach outside in all seasons

Compensation and Benefits:

• The compensation increases based on years of experience and ranges from $22.25–$35.60 hourly
• BHCHP full‑time employees are eligible for our competitive time off program, health, dental and vision insurance, 403B retirement savings plan, pre‑tax MBTA pass program with 40% discount, additional compensation for demonstrated bilingual proficiency and more. Benefits are prorated for part‑time employees

Does this amazing opportunity interest you? Then we'd love to hear from you.

As an equal opportunity employer, Boston Health Care for the Homeless Program is committed to providing employment opportunities to all qualified individuals and does not discriminate on the basis of race, color, ethnicity, religion, sex, gender, gender identity and expression, sexual orientation, national origin, disability, age, marital status, veteran status, pregnancy, parental status, genetic information or characteristics, or any other basis prohibited by applicable law.

Covid‑19 Vaccination: Proof of Covid‑19 vaccination(s) is optional for employment. Candidates who are offered employment will be given details about how to demonstrate receipt of vaccination if they choose to.

Please Note: Employment at Boston Health Care for the Homeless is at‑will. Boston Health Care for the Homeless does not sponsor work authorization visas.