Job Description

Job Description

Job Description

Performs care management duties to assess and coordinate all aspects of medical and supporting services across the continuum of care for complex/high acuity populations with primary medical/physical health needs to promote quality, cost effective care. Develops a personalized care plan / service plan for long-term care members, addresses issues, and educates members and their families/caregivers on services and benefit options available to receive appropriate high-quality care.

Education/Experience:

Requires Graduate from an Accredited School or Nursing or a Bachelor's degree and 4–6 years of related experience (Pediatrics experience)

Develops and continuously assesses ongoing long-term care plans / service plans and collaborates with care management team to identify providers, specialists, and/or community resources needed to address member's needs

Coordinates and manages as appropriate between the member and/or family/caregivers and the care provider team to ensure members are receiving adequate and appropriate person-centered care or services

Monitors care plans / service plans and/or member status, change in condition, and progress towards care plan / service plan goals; collaborate with members, caregivers, and appropriate providers to revise or update care plan / service plan as necessary to meet the member's goals / needs

Monitors member status for complications and clinical symptoms or other status changes, including assessment needs for potential entry into a higher level of care and/or waiver eligibility, as applicable

Reviews member data to identify trends and improve operating performance and quality care in accordance with state and federal regulations

Reviews referrals information and intake assessments to develop appropriate care plans / service plans

Collaborates with healthcare providers as appropriate to facilitate member services and/or treatments and determine a revised care plan for member if needed

Collects, documents, and maintains all member information and care management activities to ensure compliance with current state, federal, and clinical guidelines

Provides and/or facilitates education to long-term care members and their families/caregivers on disease processes, resolving care gaps, healthcare provider instructions, care options, referrals, and healthcare benefits

Acts as liaison and member advocate between the member/family, physician, and facilities/agencies

Educates on and coordinates community resources. Provides coordination of service authorization to members and care managers for various services based on service assessment and plans (e.g., meals, employment, housing, foster care, transportation, activities for daily living)

May perform home and/or other site visits (e.g., once a month or more), such as assessing member needs and collaborating with resources, as required

Partners with leadership team to improve and enhance quality of care and service delivery for long-term care members in a cost-effective manner

May precept clinical new hires by fostering and building core skills, coaching and facilitating their growth, and guiding through the onboarding process to upskill readiness

May provide guidance and support to clinical new hires/preceptees in navigating within a Managed Care Organization (MCO) and provides coaching and shadowing opportunities to bridge gap between classroom training and field practice

May engage and assist New Hire/Preceptee during onboarding journey including responsibility for completing competency check points ensuring readiness for Service Coordination success

Engages in a collaborative and ongoing process with People Leaders and cross functional teams to measure and monitor readiness

Performs other duties as assigned

Comply with all policies and standards

For-profit healthcare company that provides a wide range of managed health insurance products and services, primarily for government-sponsored programs like Medicaid and Medicare, as well as individuals and families through the Health Insurance Marketplace

Company Description

For-profit healthcare company that provides a wide range of managed health insurance products and services, primarily for government-sponsored programs like Medicaid and Medicare, as well as individuals and families through the Health Insurance Marketplace

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