Family Service AssociationFamily Service Association is a comprehensive private, non-profit social service agency dedicated to the development and implementation of services designed to provide strength and support to individuals and families throughout southeastern Massachusetts.  Headquartered in Fall River, Family Service Association strives to increase the capacity of individuals and families to cope with the stresses of family life and interpersonal relationships in a positive, productive and health-improving manner.  This agency is a leading provider of professional social services in the South Coast region of Massachusetts, with a 130-year tradition of high quality.

The Long Term Services and Supports (LTSS) Community Partner (CP) Support Worker is responsible for providing support to the LTSS Care Coordinator to promote coordination in the delivery and receipt of LTSS to enrollees assigned by Accountable Care Organizations (ACO) and Managed Care Organizations (MCO).

Responsibilities include:

Conduct outreach to assigned enrollees to inform about the functions of a CP Care Coordinator, the optional nature of CP enrollment, choice in CP providers, the benefits of enrollment and the process for enrolling.

Document all outreach attempts including 3 separate attempts, and the scheduling of at least one face- to-face encounter unless the enrollee voices a preference for only telephonic contact.   Schedule face-to-face meeting for enrollees with LTSS Community Partner Care Coordinator.   Prepare encounter packets with informational materials and all documents needed for enrollee engagement.   Obtain the Comprehensive Assessment from the referring ACO/MCO Facilitate approval of the LTSS Care Plan by the Primary Care Provider and sharing with all members of the enrollees care team including providers, members of state agencies and other case managers within 90 days of assignment.

Provide support for the utilization of alternative methods and formats of documentation and communication to ensure the enrollee understand the LTSS Care Plan; including but not limited to accommodation for sensory disabilities, literacy and primary language of the enrollee.

Gather and maintain resource and reference materials for area providers of LTSS, including contact information and service availability in support of facilitating enrollee access to Social Services and Community Resources.

Support Care Coordinator’s participation as a member of the enrollees care team, gathering required information related to the enrollee?s needs, preferences and service options; facilitating communication with other providers and promoting integration of care across all spectrums.

Maintain regular contact with the enrollee under the direction of the Care Coordinator.

Provide ongoing monitoring of the implementation of the LTSS Care Plan and monitoring for changes in status including health, housing, natural supports and caregivers under the direction of the Care Coordinator.

Provide support for transitions of care under the direction of the Care Coordinator.  Gather materials, curriculum and current resources in support of health and wellness coaching for enrollees regarding symptom management, health risk factors and behaviors, health promotion and setting and achieving health and wellness goals.   Maintain all documentation required for the delivery of LTSS Community Partner services.  Foster and maintain collaborative relationships with Primary Care Providers, Social Service Providers and representatives from state agencies.

The ideal candidate must have a minimum of a High School Diploma and three years  experience in a related capacity. Must have strong written and oral communication skills and demonstrated computer skill

Bi-lingual Spanish/English speaking is required.  The position is based in New Bedford area and includes travel to Fall River, Cape Cod and surrounding areas.

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