Team Coordinator / Sr. Case Manager

Job Description

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.

Job Summary :

Hours :   Full Time, Monday – Friday 8 : 30am – 5 : 00pm

Union : Yes

Union Name : 1199 SEIU

Patient Facing : Yes

Our doctors and nurses do heroic work every day, caring for some of the most vulnerable members of our community. Yet true healing often requires more than clinical care alone—it takes connection, coordination, and compassion beyond the exam room.  To meet this critical need, we are excited to introduce a new, non-clinical, two-part role on our Street Team. This position combines complex case management within the Behavioral Health Community Partners (BH CP) care management program with leadership responsibilities as a Senior Case Manager.

In this role, you will collaborate closely with a multidisciplinary team to support highly vulnerable, predominantly unsheltered individuals experiencing mental illness and / or substance use disorders. You will play a key role in connecting individuals to behavioral health services, primary care, and essential social determinants of health supports—helping them navigate systems, build stability, and move toward improved health and well-being.

If you are driven by mission, thrive in complex environments, and want your work to make a meaningful difference every day, this is an opportunity to be part of something truly impactful.

Responsibilities :

• In your role as BH CP Team Coordinator for the Street Team, you will oversee outreach, enrollment, and ongoing case management for our Street Team.
• Orient and train staff members to BH CP processes, requirements, and practices.
• Identify patients already empaneled to the Street Team for primary care who are appropriate for referral to the BH CP to ensure the Street Team BH CP panel remains full; support the Care Coordinator and Nurse Case Manager in outreaching referred patients for enrollment to the BH CP.
• Ensure completion of patient Comprehensive Assessment and Care Plan in a timely way and in accordance with MassHealth requirements; monitor and commmunicate your team’s performance on metrics such as hospital discharge follow-up and timely care plan completion.
• Attend BH CP meetings on a monthly, weekly or as needed basis and ensure the attendance of other Street Team BH CP members.
• In your role as a Senior Case Manager on the Street Team, you will be part of an integrated and multidisciplinary team that seeks out the individuals who experience chronic unsheltered homelessness.
• As part of a team, engage with and care for patients across a variety of settings including outpatient clinic at Massachusetts General Hospital, street outreach, patients’ homes and in facilities.
• Coordinate and lead monthly meetings with housing partners regarding currently housed patients empaneled to the Street Team; represent the Street Team at housing related meetings run by the City of Boston and other agencies regarding unsheltered patients empaneled to the Street Team
• Coordinate and lead 1-2 case conferences per month for high risk patients empaneled to the Street Team; coordinate and lead quarterly Street Team discussions to ensure street outreach is occurring in appropriate locations across the City of Boston.
• Assist with insurance barriers, referral for benefits, transportation, provide reminder calls for visits, and proactively contact patients to remind them about appointments; assist clients identify health-related social service needs, help them access related resources, and support the successful utilization of these resources.
• Document each patient encounter in the electronic medical record.
• Explicitly strive for equitable access to primary care services for chronically unsheltered patients of all races, ethnicities, and genders

Qualifications :

To succeed in this role, you’ll bring strong leadership skills and have the confidence to collaborate within a cross-sector team that is based in various locations across Boston, providing feedback regarding population health. You must have experience caring for underserved populations, navigating homeless / housing services and the health care system. In addition, we’re looking for a candidate who will :

Education and background :

Team coordinator(s) shall have at minimum :

An associate degree and at least one-year professional experience in the field; or

At least three years of relevant professional experience.

Compensation and Benefits :

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.

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