Social Worker Case Manager- Chronic Care C3


Lynn Community Health Center is a member of Community Care Cooperative (C3), an organization formed by 13 Federally Qualified FQHCs located throughout the Commonwealth of Massachusetts. C3, a 501(c)(3) non- profit Accountable Care Organization (ACO), is taking responsibility for managing the cost and quality of health care for MassHealth enrollees. C3’s vision is transforming the health of underserved communities.  As a member of C3, Lynn Community Health Center is uniquely positioned to be a true innovator in transforming care for a large Medicaid population.

Lynn Community Health Center is seeking Behavioral Health Specialists to join our Complex Care Management Team. You will join our team of nurses, social workers, community health workers, providers, and pharmacists, where you will have the opportunity to make a profound impact on the lives of underserved individuals and families living with complex and/ or chronic medical and behavioral conditions.  You will connect with your enrollees in person, on the phone, and in the FQHC - essentially however and wherever the enrollee needs your assistance to improve their health, better understand their illness and coordinate their care. Must be prepared to work from a FQHC, home office, or within enrollee’s homes. 


  • Respect and maintain patient confidentiality in all aspects of care including use of electronic information. 
  • Treat all patients in a welcoming and professional manner.
  • Demonstrate professionalism by appropriate attire, attendance, attitude, and behavior within the clinical setting.
  • Contribute to the team effort by supporting all team members and maintaining an open and positive attitude.
  • Welcome new employees and students to the team by assisting with their orientation to the team and mentoring them, as requested.


  • Connect with the enrollees in person (at their primary care location, their home or another community based setting or care setting). The BH Specialist will be the primary point of contact for members whose priority health concerns are behavioral health related.
  • Provide face-to-face interaction with enrollees and their care team when appropriate to improve enrollee care.  Although face-to-face care is preferred, phone contact will be used when needed and appropriate. 
  • Along with other members of the Complex Care Management (CCM) Team, conduct comprehensive assessments that include the medical, behavioral, and social needs of the enrollee in order to identify gaps in care and barriers to attaining improved health.  Complete these assessments within specific timeframes.
  • Based on this assessment, and in conjunction with the enrollee, the enrollee’s primary care provider, behavioral health provider, and other members of the CCM team, create and implement a care plan that will address the identified needs, remove the barriers and improve the health of the enrollee. Complete these care plans within specific timeframes.
  • Coordinate care by serving as the contact point, advocate and resource for the enrollee, their family and their providers, building effective relationships through trust, respect and communication.
  • In close collaboration with the enrollee, primary care provider and care team continually assess the enrollee’s knowledge of their clinical condition(s) and provide education and self-management support based on the enrollee’s unique learning style.
  • Measure, improve and maintain quality outcomes (clinical, financial, and functional) for individual enrollees and the population served.
  • Coordinate care with Behavioral Health Community Partners (BH CPs) and refer enrollees, as appropriate, to these and other community resources
  • Be fully accountable for the completion of work within established timeframes and for achieving the goals established for the enrollee/family.
  • Ensure that all care management is offered in a culturally and linguistically appropriate manner and with disability competence
  • Ensure that all needed accommodations are consistently made for members with disabilities. 
  • Maximize the use of ACO care management tools and technology to ensure that work is comprehensive, detailed, automated and streamlined to the extent possible.  Make recommendations to change workflows to enhance the ease of use, practicality and effectiveness of the ACOs tools and processes.
  • Supervise staff as assigned.
  • Understand the relationship between work done in the ACO’s system and the work done in the FQHC’s EHR.  Ensure that workflows are optimized to recognize and support both the ACO’s system and the FQHC’s EHR.
  • Use information about data trends for self-directed learning and performance improvement


  • Demonstrates an understanding of customer service principles by successfully completing on-line Customer Service training.
  • Utilizes the principles of customer service when interacting with patients/clients, team members and staff from other departments.
  • Appropriately handles or seeks support when customer service breakdowns occur.


  • Demonstrates knowledge of culture by successfully completing the on-line training on Cultural Competence.
  • Utilizes an appreciation of and respect for diversity when interacting with patients/clients, team members and staff from other departments.
  • Responds appropriately or seeks support when confronted with cultural biases or conflicts.


  • Is aware that in order to respond promptly and appropriately to emergencies, any staff member may be assigned temporary duties that differ from those in the job description, or may be assigned temporarily to a different location or schedule.
  • Understands that all staff should have a Personal Emergency Plan in place to best respond to his/her job responsibilities should a health center emergency arise.



  • Licensed Independent Clinical Social Worker (LICSW), Licensed Clinical Social Worker (LCSW), or Licensed Social Worker (LSW)
  • A current Massachusetts license for your discipline
  • 4 plus years’ experience in social or behavioral health
  • 3-5 years of experience in providing direct services to individuals with behavioral health conditions
  • Pediatric experience is a plus
  • Bachelors Degree in Psychology, Social Work, or related field. Masters preferred 

EXPERIENCE (preferred):

  • Exceptional communication skills, both written and oral, ability to positively influence others with respect and compassion
  • Fluency in a non-English language
  • Strong work ethic built on a foundation of proactivity and teamwork
  • Ability to navigate ambiguity with the aid of structured problem solving techniques
  • Committed to the practice of inquiry and listening
  • Flexible work schedule – may need to work evenings/ occasional weekends to provide enrollee access and/ or follow up
  • Computer proficiency in Microsoft Office
  • We are looking for team members who possess high energy, a strong work ethic, integrity, who are kind and empathetic, have a sense of humor, and who enjoy working for a collaborative, team oriented system 


  • The essential duties of this position may present risk of exposure to airborne infection, body fluids, and blood borne pathogens. 
  • Annual BBP Training is required. 
  • Up to date immunization and annual TB testing is required. 
  • Hepatitis B vaccine and annual flu immunization are strongly recommended. 
  • Results of inquiry to Criminal Offender Record Investigation (CORI) must be acceptable under health center standards.

Lynn Community Health Center (LCHC) provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, LCHC complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, and transfer, leaves of absence, compensation and training. LCHC expressly prohibits any form of workplace harassment based on race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, genetic information, disability, or veteran status. Improper interference with the ability of LCHC’s employees to perform their job duties may result in discipline up to and including discharge. 

Job Posting ID # 21-065