Falmouth, MA


The Care Coordinator is responsible for building trusting and productive relationships with assigned enrollees in the Community Partnership (CP) in order to help them find and obtain the services and supports necessary for health and community stability. The Care Coordinator will work with engaged enrollees to identify their goals and needs and build the Patient Centered Treatment Plan (PCTP) with the team. The Care Coordinator will outreach to all assigned enrollees, including face to face meetings in clients’ homes or community. The Care Coordinator will collaborate with various service providers and wellness resources in response to the member’s behavioral and medical health care goals and coordinate with providers to meet clients’ goals.


• Outreach to all assigned enrollees in order to engage and enroll members in CP
• Utilize motivational interviewing strategies to engage assigned members
• Works with engaged enrollees to build PCTPs that meet the clients’ unique needs and goals
• Provides support, triage, and care coordination services to positively impact the level of behavioral health and medical care needed for the enrollee
• Works with enrollees and their team to solve problems, provide access to services and resources, and advocate for enrollees
• Makes contact with their engaged enrollees who have been in the emergency department or inpatient hospitalization within 72 hours of discharge in order to update PCTP and coordinate services that support their discharge plan
• Locates and coordinates public, private, and community-based services and resources for clients to help them meet their wellness and goal attainment
• Provides direct health and wellness coaching for medical and behavioral health goals of the member
• Assists enrollees in making and keeping primary care and other medical appointments, including facilitating transportation and/or accompanying them to appointments, when necessary
• Facilitates communication between medical and behavioral health providers, community providers, family members, natural supports, and enrollee in order to
• Participates in care team meetings
• Participates in all CP training expectations
• Demonstrates an ability to work flexibly and collaboratively as a member of the CP Team
• Meets all documentation and audit requirements
• Follows South Shore Mental Health and department policies and procedures for attendance.
• Provides an environment of quality service that addresses the needs of the member, vendor, community and
South Shore Mental Health
• Follows the South Shore Mental Health’s and department policies regarding professional ethics and confidentiality
• Completes Critical Incident Reports as needed
• Remains knowledgeable regarding the utilization of the program’s emergency preparedness plan and emergency responses, code gray, fire, psych emergency, etc.
• Completes all required mandatory training
• Performs all other duties as assigned

Education: Bachelor’s degree in Psychology, Human Services or related field or professional work in care coordination

Experience: Experience with individuals with behavioral health conditions. Valid driver’s license and access to personal vehicle

Req Number# 1133

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