Community Support Specialist Bilingual Spanish-West Region

Vitra Health is a mission-driven healthcare organization committed to improving the quality of life for individuals and families across Massachusetts. Through innovative home- and community-based services, Vitra supports aging adults, people with disabilities, and individuals with complex care needs— supported by a Nurse, and Case Manager, Vitra ensures clients receive compassionate, personalized, and dignified care.

To help share our mission and expand our community impact, Vitra Health is seeking a Community Support Specialist who is passionate about community engagement and helping people access the care and resources they deserve.

The Opportunity

The Community Support Specialist is responsible for developing and maintaining positive relationships with providers, healthcare organizations, and community service agencies to ensure comprehensive support for all program participants. This position coordinates the delivery of social services, evaluates all clients enrolled in the program, and formulates individualized plans of care in collaboration with nurses and healthcare providers.

The role also ensures that all client charts are maintained in a neat and organized manner and that all required documentation is completed accurately and in accordance with company policies and state regulations. In addition, the Community Support Specialist provides culturally appropriate health education, information, support, and counseling to members and their caregivers in compliance with all applicable standards and guidelines. This position will require working two to three days in the Braintree HQ as needed and two days in the field.

Key Responsibilities

• Conduct on-site visits with each client and caregiver at the qualified setting. • Obtains a social history and conducting a psycho-social evaluation. • Conducts ongoing evaluations of the AFC and/or GAFC setting. • Select, train, evaluate, and supervise AFC caregivers with the registered nurse and case manager. • Participate in the development, implementation, and ongoing review of the AFC plan of care • Presents, plans, and implements social service interventions. • Complete a care-management progress note corresponding with each on-site visit or encounter and upon significant change. • Assist with obtaining information and accessing other healthcare and community services. • Participate in discharge and transition planning and implementation. • Review and document the fire and safety procedures for the qualified setting. • Review AFC caregiver task logs at a minimum of every 30 days and report findings to the registered nurse and case manager. • Review at least annually the suitability of the qualified setting. • Provide clients with ongoing support with ADL's and IADL's. • Provide accurate orientation to the participants of the AFC and/or GAFC program. • Coordinate all social services with the personal care team. • Partake in both care plan creations and reviews, along with discharge plans. • Has direct contact with the client and the client's caregiver, registered nurse, and case manager. • Manages all paperwork associated with admissions, referrals, visits, and medical equipment/social referrals. • Assist participants with finding community, financial and legal services. • Review and assess caregivers' clothing, equipment, supplies and other services. • Participates in weekly clinical meetings. • Performs replacement visits on behalf of Vitra's RNs, LPNs, and Case Managers as needed. • Conducts weekly calls to AFC Caregivers to confirm compliance with program regulations. • Foster culture of customer service and commitment to quality care. • Serve as a brand ambassador for Vitra reflecting our vision, mission, and values. • Show genuine interest and compassion for the communities we serve. • Other duties as assigned.