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At CHA, we are dedicated to serving our neighborhoods and our employees are at the heart of this compassionate, quality care. We are building a skilled, dynamic workforce to meet patient needs.
Job Details

Coordinator, Planned Care

Date Posted: 01/29/2023

Requisition Number: 2847

Location: CHA Cambridge Hospital 

Work Days: 8:30-5:00  

Category: Professional and Management  

Department: Planned Care Coordinators PC  

Job Type: Full time  

Work Shift: Day 

Hours/Week: 40.00 

Union: Yes 

Union Name: CH Laborers 380


Cambridge Health Alliance (CHA) is a leader in Primary Care, supporting a highly diverse population across the Boston metro-north region. Today, CHA serves more than 120,000 primary care patients during more than 300,000 annual visits. Services are available at 13 primary care centers, 3 teen health centers, via telehealth, and through some very special programs, right in patient homes. As a member of CHA Primary Care, you will be part of a dynamic team that values creativity and innovation. You will help deliver care across the entire spectrum of primary care – with internal medicine, family medicine, pediatrics, geriatrics and women’s health services. You will be in a team-based setting, where primary care works hand-in-hand with behavioral health, pharmacy, complex care and multilingual interpreter services. CHA is also a teaching hospital, with several primary care centers hosting CHA’s Harvard Internal Medicine residency and Tufts Family Medicine residency.    

The Planned Care Coordinator (PCC) will work closely with patients and their health care team utilizing the Planned Care Model. As a member of the Planned Care team, the PCC will assume the day to day responsibilities for care coordination at the sites for patient' with chronic health conditions. The PCC will perform a wide range of functions which safely, effectively, and efficiently support the patient and health care team. Responsibilities will include initiating contact with patients and their care team, working proactively to remove barriers which impede access to health care and prevents successful implementation of the treatment plan; building a supportive relationship with patients to improve the patient's utilization of necessary health services which may improve the patient's health status; assisting uninsured/underinsures patients in the application for public insurance; reviewing the chronic disease registries; outreaching to patients; assisting in patient follow up after ambulatory visits, emergency room visits, and inpatient stays. The PCC will maintain logs, analyze data, observe patterns, prepare written and verbal reports, and recommend improvements based on this information. All responsibilities of the PCC will be consistent with the scopes of practice acts governing health care clinicians in Massachusetts.

• Assumes day to day responsibilities for patient care coordination at 2-3 ambulatory care sites utilizing the Planned Care Model.
• Initiates contact with patients and their health care team, working proactively to insure access to health care services by identifying and removing barriers
• Builds a supportive relationship with patient to improve the patient's utilization of necessary primary care, mental health care, and social services, which will improve the patient's health status
• Logs in to the Planned Care registries daily, or as required by the practice site, and uses available information to facilitate timely labs, follow up encounters with clinical team, prescription renewals, etc.
• Assists clinical providers by tracking emergency department visits and hospital stays of their patients and connects with the patient after one of these episodes to schedule an appointment with primary care.
• Collaborates with multi-disciplinary team, including clinical and non-clinical staff, at practice sites and across the Alliance. Specifically, works with the team leader to provide proactive outreach and support to patients.
• Provides follow up contact with the patient after medical appointments to assess if patients understood and accepted the treatment plan and assist in removing barriers to treatments, care plans, and follow up. This would include activities such as checking if prescriptions were filled,
• Helping prepare shopping list according to nutrition plan, if follow up appointments were made, if there were questions, etc.
• Assess patient’s current health insurance status and intervenes directly or by referral when needed to assist with public insurance.
• Provides all clinical and pertinent patient information in a timely manner to the ambulatory care nurse or care manager.
• Assists in the coordination and execution follow up plans.
• Documents all patient encounters in a timely manner Maintains logs of clinical and functional measures to assist in evaluation of PCC role.
• Maintains logs, analyzes data, and makes recommendations for policies and procedures based on information and observation of patterns encountered during the work day.
• Performs other duties as assigned by supervisor


High energy individual with excellent interpersonal, organizational, and computer skills. Effectively interacts with all members of the health care team and with patients. Maintains confidentiality around patient issues. Takes initiative to proactively organize and manage the responsibilities of the job.
Language skill: Bilingual (English and Portuguese, Creole or Spanish) in the specific cultural/language group of the population/community served.
Education/Training: Bachelors degree, preferably in human services or a related field preferred.
Work Experience: Two years in a relevant human service field in a multi-disciplinary setting; experience with relevant community groups and/or in a multicultural setting preferred.

In keeping with federal, state and local laws, Cambridge Health Alliance (CHA) policy forbids employees and associates to discriminate against anyone based on race, religion, color, gender, age, marital status, national origin, sexual orientation, gender identity, veteran status, disability or any other characteristic protected by law. We are committed to establishing and maintaining a workplace free of discrimination. We are fully committed to equal employment opportunity. We will not tolerate unlawful discrimination in the recruitment, hiring, termination, promotion, salary treatment or any other condition of employment or career development. Furthermore, we will not tolerate the use of discriminatory slurs, or other remarks, jokes or conduct, that in the judgment of CHA, encourage or permit an offensive or hostile work environment.

Cambridge Health Alliance brings Care to the People - including your neighbors, friends and family. Our local hospitals and care centers serve our vibrant, diverse communities, and play an integral role in improving health. As passionate advocates for the underserved, we actively partner with our communities to take on challenging public health issues, and conduct important research to help reduce barriers to care. We believe that everyone deserves access to high quality, convenient health care. This is why our employees believe in where they work and why many build long, rewarding careers at CHA.

Healthcare is changing rapidly. CHA has a strategic plan that charts a proactive course for our future. It is built on a vision of equity and excellence for everyone, every time. It also recognizes that our workforce is our most valuable asset and prioritizes competitive salaries, benefits and professional development opportunities for employees. The strategic plan is changing the way we provide care and improving the health and experience of our patients; we are looking for smart, committed, compassionate people who want to be part of making our vision of better health and equity a reality.

At CHA, you can believe in where you work and go home every day knowing you made a difference. Join our team and help us bring Care to the People.

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