New

Care Coordinator Case Manager - Dual Eligible Special Need Plan (D-SNP)

Mass General Brigham Community Physicians
remote work
United States, Massachusetts, Somerville
399 Revolution Drive (Show on map)
Dec 05, 2025
This position's responsibilities and caseload may be adjusted based on 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. What You'll Bring* Qualification Requirements: Bachelor's Degree 1+ years of direct clinical experience (community case management) Valid Driver's License and reliable transportation Competency in working with multiple health care computer platforms (e.g. EPIC) Preferred Skills: Experience with Dual Eligible Populations (Medicare and Medicaid) Experience working with individuals with complex medical, behavioral, and social needs NCQA knowledge Additional Knowledge, Skills, and Abilities 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 This is a full-time position with a schedule of Monday through Friday, 8:30 AM-5:00 PM EDT This is a hybrid schedule, which includes practice-based work, remote work, and in-person home and community visits (these days will vary weekly and these visits may increase as the program launches) Must be local, ideally in Eastern, MA with the ability to travel to the community. This role offers autonomy to build own schedule to accommodate members' needs. 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 work, remote work, and in-person home and community visits with members. The member population will reside primarily in Essex, Middlesex, Suffolk, Norfolk, Plymouth, Bristol, Dukes, and Nantucket counties. The responsibilities and caseload may be adjusted based on enrollment trends. Mass General Brigham Community Physicians, 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.