The Long Term Services and Supports Care Coordinator (LTSS CareCoordinator) is tasked with improving Enrollee health outcomes andreduce Enrollee cost of care. The LTSS Care Coordinator is responsiblefor implementing all appropriate required Enrollee level MassHealthcontractual and pay-for-performance requirements. The LTSS CareCoordinator participates in multi-disciplinary care team meetings.Assist Enrollee in accomplishing goals of the LTSS Care Plan. Examplesor duties may include the following: - Collaborate with the Enrollee\'scare team (registered nurse, PCP, PCA, medical director, behavioralhealth specialists, social workers, etc.). - Encourage Enrollee tofollow treatment recommendations through support, health and wellnesseducation, and advocacy. - Link Enrollees with resources and encouragethem to use them to their advantage. - Utilize recovery strategies suchas Motivational Interviewing, Harm Reduction and Strength Basedapproaches to support enrollees in attaining stated goals. - Conductvisits in the home or in other locations in the community to provideguidance, support, education and coaching. Follow-up by telephone asnecessary. - Accompany Enrollees to medical appointments as requested;facilitates effective navigation of the health care system Adhere toMassHealth contractual requirements. - Complete minimum monthly contactwith Enrollees and document the qualifying activity by utilizingappropriate activity codes and related modifiers as specified byMassHealth. o Examples of Qualifying Activities include the following:Outreach, assessment, care planning, care transitions and dischargefollow-up, connection to community, social service, and flex supports,and coaching. - Completion of a Care Plan and Social Service Assessmentannually. This includes coordination with the Enrollee\'s MedicalHome. - Utilization of the EMR Event tracking system. This includes, butis not limited to checking for daily Alerts, tracking updates of theCare Plan status, and documentation of the ACO Assessments. The LTSSCare Coordinator will complete duties related to pay-for-performancemetrics as determined by MassHealth, EOHHS, and CMS. Examples of theseduties are as follows: - Assist Enrollees in having an annual primarycare visit. - Complete a Care Plan annually. The Care Plan must besubmitted to PCP no less than 30 days prior to expiration on 1-yearrequirement. - When requested, perform Engagement tasks including, butnot limited to, outreach and obtaining initial enrollment paperwork. -Complete a face-to-face visit within 3 business days to Enrollees afteracute or post-acute stay as requested. - Ensure that Enrollee has anannual oral health evaluation. Maintain the ability to adapt and remainflexible with changing MassHealth, EOHHS, and CMS requirements andongoing clarifications of the Community Partner Program. EqualOpportunity Employer/Protected Veterans/Individuals with DisabilitiesThe contractor will not discharge or in any other manner discriminateagainst employees or applicants because they have inquired about,discussed, or disclosed their own pay or the pay of another employee orapplicant. However, employees who have access to the compensationinformation of other employees or applicants as a part of theiressential job functions cannot disclose the pay of other employees orapplicants to individuals who do not otherwise have access tocompensation information, unless the disclosure is (a) in response to aformal complaint or charge, (b) in furtherance of an investigation,proceeding, hearing, or action, including an investigation conducted bythe employer, or (c) consistent with the contractor\'s legal duty tofurnish information. 41 CFR 60-1.35(c)