Care Coordinator BHCP

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Location: Danvers, MA
Job ID: 154194-1A
Date Posted: Sep 6, 2019
Category: Specialist

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Job Description

Welcome To

Lahey Health Behavioral Services is part of a vibrant and growing health care system, recognized as a trailblazer in medicine and a standard bearer in patient experience. It includes an award-winning academic medical center, a superb constellation of community hospitals, home care services, rehabilitation facilities and more.

We are committed to attracting, developing and retaining top talent in a market long recognized and revered as a global leader in health. With a team approach to care, we encourage learning and growth at all levels, and we offer competitive salaries and benefits. We adhere to the principles of a just and fair work environment for all colleagues, where respect is foundational and performance is rewarded.

About the Job

The Behavioral Health Community Partner (BHCP) program at Lahey Health Behavioral Services is a new, innovative Care Management program for MassHealth members that are part of the new Accountable Care Organization (ACO) and or a Managed Care Organization (MCO). Care Coordinators are community health workers (CHWs), health outreach workers, peer specialists, recovery coaches

Care Coordinator performs outreach and engagement, care coordination, care management, and care transition functions and activities for individuals with high behavioral health needs and enrollees in the BH CP program. The Care Coordinator, under the direction of the Lead care coordinator and BH CP Clinical Care Manager, is a Member of the Care Team and a key contributor to the Care Planning process. The CC monitors the Members adherence and response to the Care Plan.


40 hours, full time. 

Mon-Friday, days.



  • Adhere to all policies and procedures relative to outreach and engagement, care coordination, care management, and care transition functions and activities;
  • Assume responsibility for a mixed acuity case load;
  • Facilitate consents, gathering of clinical information (including all existing medical, behavioral health and treatment plans) and discussion with enrollee’s BH and medical providers
  • Conduct outreach and outreach engagement activities and provide information about the benefits, design and purpose of the CP Supports
  • Facilitate the scheduling of and conduct the comprehensive assessment, face-to-face whenever possible and appropriate;
  • Identify need for interpreter service, cultural considerations, preferences, and accommodations;
  • Utilize person-centered framework to identify the enrollee’s and/or caregivers goals, preferences, and desired level of involvement;
  • Develop and maintain crisis plans and communicate the individual’s self-management plan
  • Under the direction of the clinical case manager, assist in the forming and operation of a Care Team for each engaged Enrollee
  • Facilitate communication among and coordinate with the Engaged Enrollee, the PCP, and other providers who serve the Engaged Enrollee
  • Execute the activities necessary to support the Engaged Enrollee’s Person-Centered Treatment Plan and to ensure the Engaged Enrollee has timely and coordinated access to primary, medical specialty, LTSS, and behavioral health care
  • Prior to an Engaged Enrollee’s inpatient discharge or change in treatment setting, assist in the development of an appropriate discharge plan, in coordination with the Engaged Enrollee, the Engaged Enrollee’s PCP, ACO, MCO and other providers, as appropriate. 
  • Develop and maintain collaborative relationships with community based organizations in the Contractor’s Service Area
  • Continuously identify and help resolve barriers to meeting goals and complying with the CP;
  • Facilitate enrollee referrals to resources including medical appointments as directed by the CP and conduct ongoing follow-up
  • Assess progress against the CP and goals and update as appropriate;
  • Assist enrollee in navigating the network of community based services and information;
  • Support safe transitions in care for enrollees moving between settings;
  • Provide temporary assistance with transportation to needed medical/BH appointments when needed while transitioning to community-based transportation, (e.g., assisting enrollee with the PT1 form).
  • Facilitate communication between the enrollee or designated representative and enrollee’s healthcare providers;
  • Attend integrated rounds meeting as scheduled or as requested;
  • Participate in supervision with LHBS BH CP clinical Care Manager;
  • Participate in all trainings conducted or directed by LHBS;
  • Conduct health and wellness coaching activities, offer materials in preferred language and formats when needed;
  • Support enrollee with medication referrals and management
  • Ensure enrollee screening of medical conditions, identification of medical PCP, and connection to medical provider(s) as needed
  • Must have the ability to follow oral and written directions as they relate to the functions listed above. Must have excellent oral, written and interpersonal communication skills to effectively interact with Division leadership, staff, and external stake holders. Must have the ability to organize, prioritize and multi-task workload in a fast paced environment, handle confidential matters with discretion and maintain a professional demeanor. Ability and desire work with a diverse and multicultural setting.


  • High school graduate or equivalent required. Bachelor's Degree from an accredited university in psychology, social work or related human services field preferred
  • 1-3 years’ experience in community-based behavioral health support program preferred.
  • Ability and desire work with a diverse client population.
  • Strong communication skills (both written and verbal)
  • Strong time management and organization skills
  • Must demonstrate good boundaries regarding confidentiality and personal relationships
  • Strong ability to evaluate what is needed by each individual and adjust approach accordingly.
  • Experience with accessing local resources and navigating mental health and/or substance abuse treatment systems.
  • Proficiency with electronic health record documentation or ability to complete documentation electronically is required. Working knowledge of windows operating system and standard desktop applications such as Windows and Microsoft Suite                 

Physical Requirements

Must be able and willing to transport enrollees served. As such, must have a valid driver's license, good driving record, and reliable vehicle. Travel and an ability to meet persons served in a variety of outreach settings is required. Some flexible hours to accomplish outreach and engagement of enrollees at times when they are reachable; this may involve some early evening hours or later work days.

About Us

The Lahey Model of Care—right care, right time, right place—is exactly what patients, providers and payers need and deserve. Identifying and delivering on this convergence of interests has positioned Lahey Health for further growth. Our model ensures care is highly coordinated and locally delivered, with lower costs and exceptional quality.

Lahey Health is a robust, regional system including a teaching hospital, community hospitals, primary care providers, specialists, behavioral and home health services, skilled nursing and rehabilitation facilities, and senior care resources throughout northeastern Massachusetts and southern New Hampshire. The system has a global presence with programs in Canada, Jordan and Bermuda.

Equal Opportunity Employer/Minorities/Females/Disabled/Veterans.