Mass General Brigham Community Physicians, Inc., a not-for-profit organization supporting patient care, research, and community service, is seeking a Care Coordinator Case Manager for its Dual Eligible Special Need Plan (D-SNP). In this hybrid role, you will serve as the Interdisciplinary Care Team Lead for members with low to moderate complexities, conducting assessments, developing care plans, and providing health education through a mix of practice-based work, remote work, and in-person home and community visits.
What You'll Do
- Collaborate with interdisciplinary care teams including primary care providers, specialists, LTSC, and GSSC to support program enhancements and comprehensive care coordination.
- Participate actively in interdisciplinary care team meetings and establish consistent communication with providers and enrollees.
- Develop, update, and implement individualized, enrollee-centered care plans in partnership with enrollees and the care team.
- Conduct outreach, assessments, and home visits via telephonic, electronic, or in-person methods to evaluate clinical status and identify needs.
- Monitor enrollees’ clinical status, identify early signs of deterioration, and intervene proactively to prevent unnecessary hospitalizations.
- Provide enrollee and family health education, coaching, and routine engagement tailored to individual needs.
- Utilize electronic medical record systems to accurately document, monitor, and evaluate interventions and care plans.
- Serve as a clinical resource and lead interdisciplinary care team member for assigned enrollees.
- Perform additional duties as assigned to support the overall goals of care management and enrollee well-being.
What We're Looking For
- Bachelor's Degree
- 1+ years of direct clinical experience in community case management
- Valid Driver's License and reliable transportation
- Competency in working with multiple health care computer platforms
Nice to Have
- Experience with Dual Eligible Populations (Medicare and Medicaid)
- Experience working with individuals with complex medical, behavioral, and social needs
- NCQA knowledge
Technical Stack
- EPIC
Team & Environment
You will be part of an interdisciplinary care team within a high-performing organization that believes in driving groundbreaking medical discoveries.
Benefits & Compensation
- Compensation: $54,308.80 - $78,904.80 annually
Work Mode
This role follows a hybrid work model, combining practice-based, remote, and in-person work. Travel is required for home and community visits across locations including 399 Revolution Drive, Essex, Middlesex, Suffolk, Norfolk, Plymouth, Bristol, Dukes, and Nantucket counties.
Mass General Brigham Community Physicians, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law.
