Care Coordinator Case Manger

Mass General Brigham Health Plan
remote work
United States, Massachusetts, Somerville
399 Revolution Drive (Show on map)
Oct 30, 2025
The Opportunity Care Coordinator Mass General Brigham Health Plan is hiring two Care Coordinators to work as part of an interdisciplinary care team providing care management for health plan enrollees with medical, behavioral, and social needs, including Severe and Persistent Mental Illness (SPMI). The Care Coordinator serves as the Interdisciplinary Care Team Lead for enrollees with low to moderate complexities and acts as a key partner in navigating Mass General Brigham's Health Plan, MassHealth, and Medicare services. As an expert on the interdisciplinary team, the Care Coordinator conducts assessments, develops enrollee centered care plans, coordinates care, provides health education, and collaborates with providers to ensure comprehensive support. The Care Coordinator engages with Community Based Organizations to support social engagement, recovery, Social Determinants of Health, wellness, and independent living. This position requires a hybrid work model, including practice-based, remote work and enrollee in-person home and community visits when needed. The population will primarily include enrollees residing in Essex, Middlesex, Suffolk, Norfolk, Plymouth, Bristol, Dukes, and Nantucket counties. This position's responsibilities and caseload may be adjusted based on enrollee enrollment trends. Collaborate with interdisciplinary care teams-including primary care providers, specialists, LTSC, and GSSC-to support program enhancements, process improvements, and comprehensive care coordination. Participate actively in interdisciplinary care team meetings and establish consistent communication and reporting with providers and enrollees to review status, progress, and address challenging situations. Develop, update, and implement individualized, enrollee-centered care plans in partnership with enrollees and the care team, incorporating self-care, shared decision-making, and behavioral health considerations. Conduct outreach, assessments, and home visits via telephonic, electronic, or in-person methods to evaluate clinical status, identify needs, and provide ongoing community-based care management or referrals as appropriate. Monitor enrollees' clinical status, identify early signs of deterioration, and intervene proactively to prevent unnecessary hospitalizations; act as clinical escalation point for urgent issues, providing triage and care coordination. Provide enrollee and family health education, coaching, and routine engagement tailored to individual needs, facilitating access to providers and supportive services. Utilize electronic medical record systems to accurately document, monitor, and evaluate interventions and care plans in compliance with DSNP regulations and organizational policies. Serve as a clinical resource and lead interdisciplinary care team member for assigned enrollees, supporting compliance initiatives, quality assurance, and collaboration with care management leadership. Perform additional duties as assigned by supervisors to support the overall goals of care management and enrollee well-being. Candidate Requirements* Degree: Bachelor's Degree Required Field of Study: Bachelor of Arts (BA) or Bachelor of Science (BS) in social work, human services, or related field plus experience with population preferred Valid Driver's License and reliable transportation Minimum 3 years of direct clinical experience Experience with community case management Experience with Dual Eligible Populations (Medicare and Medicaid) NCQA experience preferred Competency in working with multiple health care computer platforms, nice to have EPIC experience Experience working with individuals with complex medical, behavioral, and social needs Skills for Success Exceptional communication and interpersonal skills to effectively engage with enrollees and interdisciplinary teams Critical thinking and problem-solving skills. Demonstrates autonomy in decision making Strong organizational skills with an ability to manage routine work, triage and reset priorities as needed Interpersonal skills and ability to work effectively with providers and their staff to develop rapport, build trust, and promote Population Health initiatives. Excellent oral, written, and telephonic skills and abilities Competency in working with multiple health care computer platforms Ability to work effectively in a complex fast paced medical environment and multiple practice locations Ability to work independently while contributing to a collaborative team environment Knowledge of healthcare and community services to assist enrollees effectively Must be comfortable with change, have the ability to adapt and pivot as part of continuous process improvement activities Working Model Required M-F Eastern Business Hours required 830a-5pm ET Onsite Practice-based, remote work and enrollee in-person home and community visits Weekly multiple days in field needed, will vary Reliable transportation and valid driver's license required Must be local, ideally in Eastern, MA. Community capable with autonomy to build own schedule to accommodate member's needs. With flexibility required based on member needs Must be flexible for training, field work and business needs, this can very per week in person, as well as telephonic or virtual assessments are possible. Field work may be increased as the program launches Remote working days require stable, quiet, secure, compliant working station and access to Teams Video via MGB equipment Our goal will be to geographically align employees, this depends on residence, and can vary based on business needs, member enrollment and team staffing. Employee must accommodate the hybrid work model, including practice-based, remote work and enrollee in-person home and community visits. The population will primarily include enrollees residing in Essex, Middlesex, Suffolk, Norfolk, Plymouth, Bristol, Dukes, and Nantucket counties. The responsibilities and caseload may be adjusted based on enrollee enrollment trends. Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. 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. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.