Care Coordinator Case Manger

Site: Mass General Brigham Health Plan Holding Company, Inc.

Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.

MGB Health Plan is hiring two Care Coordinator Case Mangers!

Department: Duals Coordinator Whole Health Care, Mass General Brigham Health Plan

The roles are hybrid, requiring travel and commuting in the community

Job Summary

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.
  
  

Qualifications

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
  
  

Additional Job Details (if Applicable)

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.

Remote Type

Hybrid

Work Location

399 Revolution Drive

Scheduled Weekly Hours

40

Employee Type

Regular

Work Shift

Day (United States of America)

Pay Range

$62,400.00 - $90,750.40/Annual

Grade

6

At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package.

EEO Statement

Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. 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. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran’s Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642.

Mass General Brigham Competency Framework

At Mass General Brigham, our competency framework defines what effective leadership “looks like” by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.