Home First Case Manager

Overview

Starting rate $27.25 / hour

or

$27.75 / hour if bilingual Spanish or Portuguese speaking

The Home First Case Manager provides intensive, family-centered support to medically complex children and young adults ages 3-25, and their caregivers. This role focuses on conducting comprehensive assessments, developing and updating Family Support Plans (FSPs), coordinating and brokering services, and helping families navigate medical, behavioral health, educational, and community systems. Through referral, advocacy, and flexible funding allocations, as appropriate, the Case Manager helps build family capacity to safely support the individual at home and in the community.

This is a home-based position with frequent travel throughout the DDS Metro Region to visit families in their homes, hospitals, schools, and other community settings, as well as periodic in-person meetings in the Worcester area. Hours are primarily Monday–Friday, 9 : 00 a.m.–5 : 00 p.m., with flexibility as needed to meet the needs of families, the Department of Developmental Services (DDS), and occasional outreach events.

Minimum Education Required

High School Diploma / GED

Additional Shift Details

frequent travel throughout the DDS Metro Region and Worcester area

Responsibilities

• Conduct comprehensive assessments of individuals living with medica and their families, including home visits, using referral and intake tools to identify strengths, risks, and areas of need.
• Develop an initial and subsequent Family Support Plans (FSP) with each assigned family, reflecting medical, behavioral, and social needs, and review / renew it at least annually or as needs change.
• Provide individually tailored support, advocacy, and care coordination to help families navigate complex medical, behavioral health, and community systems and achieve the goals outlined in the FSP.
• Broker and arrange services on behalf of individuals and families, including home- and community-based supports, respite, and medical related resources (e.g., CCM, PCA, DME, transportation, in-home supports).
• Coordinate and secure referrals to all necessary services, including specialty medical providers, behavioral health providers, school systems, community agencies, and state programs (e.g., DDS, MassHealth, DPH), as applicable.
• Collaborate closely with DDS and other involved agencies to ensure appropriate, timely, and coordinated services for families with complex medical needs.
• Prepare and submit ongoing progress updates and reports to the Supervisor, DDS, and other funders as required, documenting changes in medical status, service needs, and progress toward FSP goals.
• Provide or arrange transportation for individuals, when needed and as approved, to support access to medical appointments, services, and community activities.
• Comply with Mandated Reporter laws by reporting any reasonable suspicion of abuse or neglect to the Department of Children & Families (DCF) and / or the Disabled Persons Protection Commission (DPPC).
• Attend and actively participate in DDS quarterly review meetings and other care planning meetings (e.g., hospital discharge planning, school meetings) as needed.
• Attend required trainings and maintain all necessary certifications (e.g., CPR, First Aid, Safety Care), including training related to working with medically complex individuals when offered.
• Attend and actively participate in supervision sessions and staff meetings, bringing forward changes in medical status, risk, and support needs.
• Ensure that all individuals and families are treated with dignity and respect in accordance with Advocates’ Human Rights Policy, with sensitivity to the stressors of caring for medically complex loved ones.
• Perform all responsibilities in accordance with agency policies, procedures, and regulatory standards, including those related to privacy and protected health information.
• Consistently meet or exceed agency performance standards, including timely documentation, follow-through on referrals, and responsiveness to urgent situations within the scope of the role.

Please note : The essential functions listed in this section are not limited only to the tasks listed and may include other duties as assigned.

Qualifications