Job Description
Job Description
Job Description
ABOUT THE ORGANIZATION
Community Health Programs is a network of health centers and caring professionals that provide outstanding primary and preventive care for patients of all ages. What's truly unique to CHP is our broad spectrum of support services that extend beyond medical and dental issues to strengthen families and improve children's well-being. The region is a federally designated rural community and a Medically Underserved Population Area.
Community Health Programs embraces its role as a nonprofit health care provider and community partner. We are a leader in the communities we serve by providing high quality healthcare, dental services, wellness education and family support services. CHP outreach provides free health screenings, insurance enrollment assistance as well as information so people can learn how to take better care of themselves and their families.
Salary Range: $70,000 - $90,000 / year Community Health Programs seek a highly motivated and detail-oriented ACO Complex Care Manager. The ACO Complex Care Case Manager for High ED Utilizers is responsible for providing intensive, wraparound support to members with frequent emergency department usage within our Federally Qualified Health Center (FQHC). This role focuses on complex care coordination, patient engagement, and integration of behavioral, medical, and social supports to reduce avoidable admissions and ED visits. Must have excellent organizational skills to support our mission of providing high-quality, accessible healthcare to underserved communities. The ACO Complex Care Case Manager works both independently and as part of a multidisciplinary team to develop care plans that address root causes of high utilization and improve member outcomes.
POSITION REQUIREMENTS ACO Complex Care Case Manager Essential Duties and Responsibilities:
Essential Skills and Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
Assessment, Engagement, and Planning:
- Conduct comprehensive assessments (telephonic, in-home, or community-based) to identify medical, behavioral, and social needs
- Build rapport using trauma-informed care, motivational interviewing, and harm reduction approaches
- Develop individualized care plans in collaboration with members, caregivers, primary care teams, and community partners
- Document member goals, barriers, and interventions in the EMR and/or case management platform
Care Coordination and Advocacy:
- Coordinate services across behavioral health, primary care, housing, food access, transportation, and other SDOH
- Provide warm handoffs to internal staff (e.g., CHWs, RNs) and external partners
- Refer and link members to community supports, Community Partners, and Long-Term Services & Supports (LTSS) programs
- Facilitate team-based case reviews and advocate for member needs across the care continuum
Monitoring and Support
- Monitor care plan progress, address gaps in care, and update care plans as needed
- Collaborate with nursing staff and behavioral health clinicians
- Track avoidable ED visits and ensure members have follow-up support after hospital or ED discharge
- Support program evaluation efforts and quality improvement initiatives related to ED utilization
Collaboration and Team Participation:
- Participate in regular team huddles, ACO partner meetings, and cross-functional workgroups
- Maintain timely, professional communication with providers, staff, and community agencies
- Participate in program development and provide feedback to enhance workflows
Key Competencies
- Knowledge of local community resources, Medicaid ACO programs, and SDOH
- Ability to prioritize, problem-solve, and manage a dynamic caseload
- Experience working with vulnerable populations, including those with SPMI, substance use disorders, or unstable housing
- Strong written and verbal communication skills
- Proficiency with Microsoft Excel and EHR platforms
Experience:
- Minimum 3–5 years’ experience in care coordination, case management, or community health
- Preferred: Experience working with high-utilizer populations, behavioral health, substance use, and social determinants of health (SDOH)
Education and Training:
- Master’s degree in social work, Mental Health Counseling, or related Human Services field required.
License/Certification:
- Active, unrestricted license as LCSW, LICSW, or LMHC in Massachusetts
- Reliable transportation required
- Certification in Case Management preferred
Physical Requirements:
Click here to view the Administrative ADA requirements.
FULL-TIME/PART-TIME Full-Time
POSITION ACO Complex Care Case Manager
EXEMPT/NON-EXEMPT Exempt
LOCATION MA, Pittsfield, CHP Neighborhood Health Center
EOE STATEMENT We are an equal employment opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status or any other characteristic protected by law.
PI001a2129d8ea-25405-37504361
Job Tags
Full time, Part time, Local area,