Community Based Care Coordinator-Duals Integrated Care

caresource; Michigan; On-site; USD 55,000 - 85,000; Full time

Job summary

caresource seeks a Community Based Care Coordinator, Duals Integrated Care, to manage and coordinate care for dual-eligible beneficiaries across community settings, integrating health services and resources for better outcomes.

The role collaborates with interdisciplinary teams, educates members and families on Medicare/Medicaid benefits, coordinates with providers, and monitors care plans while traveling to member and provider sites as required.

Qualifications

• Nursing degree from an accredited program or a health care bachelor's degree as alternative.
• Equivalent years of relevant work experience may be accepted in lieu of required education.
• Registered Nurse, Social Worker, or Clinical Counselor licensure is required per state practice.
• Case Management Certification is highly preferred.

Responsibilities

• Engage with members in community settings to build care coordination relationships.
• Coordinate between providers, community resources, and dual-eligible beneficiaries to ensure care transitions.
• Develop and implement individualized care plans based on medical and social needs.
• Lead interdisciplinary care team to address medical and non-medical needs and monitor adherence.

Skills

Microsoft Office

Interpersonal communication

Education

Nursing degree

Bachelor's degree in health care field

Tools

Outlook

Word

Excel

Job description

Job Summary

The Community Based Care Coordinator, Duals Integrated Care is responsible for managing and coordinating care for dual-eligible beneficiaries, those who qualify for both Medicare and Medicaid. This position focuses on integrating health services and community resources to improve health outcomes and enhance the quality of life for individuals with complex health needs.

Essential Functions

• Engage with the member in a variety of community-based settings to establish an effective, care coordination relationship, while considering the cultural and linguistic needs of each member.
• Function as a liaison between healthcare providers, community resources, and dual-eligible beneficiaries to ensure seamless communication and care transitions.
• Conduct comprehensive assessments to identify the physical, mental, and socials needs of dual-eligible individuals.
• Develop and implement individualized care plans based on unique needs of each member, considering their medical, social, and behavioral health requirements.
• Lead and collaborate with interdisciplinary care team (ICT) to create holistic care plans that address medical and non-medical needs.
• Assist members in accessing community resources, including housing, transportation, food assistance, and social services.
• Educate members about their benefits and available services under both Medicare and Medicaid.
• Provide education to members and their families about managing chronic conditions, medication adherence, and preventive care.
• Promote health lifestyle choices and self-management strategies.
• Regularly monitor member's health status and care plan adherence, adjusting, as necessary.
• Follow up with members after hospitalizations or significant health events to ensure continuity of care and prevent readmissions.
• Work closely with primary care physicians, specialists, and other healthcare providers to coordinate care and share relevant information.
• Coordinate with community-based organizations, other stakeholders/entities, state agencies, and other service providers to ensure coordination and avoid duplication of services.
• Participate in care team meetings to discuss member progress and address barriers to care.
• Maintain accurate and up-to-date records of members interactions, care plans, and outcomes.
• Collect and analyze data to evaluate the effectiveness of care coordination efforts and identify areas of improvement.
• Advocate for the needs and preferences of dual-eligible beneficiaries within the healthcare system.
• Empower members to take an active role in their healthcare decisions.
• Evaluate member satisfaction through open communication and monitoring of concerns or issues.
• Regular travel to conduct member, provider and community-based visits as needed and per the regulatory requirements of the program.
• Report abuse, neglect, or exploitation of older adults as a mandated reporter as required by State law.
• On-call responsibilities as assigned.
• Adherence to NCQA and CMSA standards.
• Performs any other job related duties as requested.

Education and Experience

• Nursing degree from an accredited nursing program required or
• Bachelor's degree in a health care field required
• Equivalent years of relevant work experience may be accepted in lieu of required education
• Previous experience in nursing, social work, counseling or health care profession (i.e. discharge planning, case management, care coordination, and/or home/community health management) experience required
• Prior experience in care coordination, case management, or working with dual-eligible populations preferred
• Medicaid and/or Medicare managed care experience preferred

Competencies, Knowledge and Skills

• Intermediate proficiency level with Microsoft Office, including Outlook, Word and Excel
• Understanding of Medicare and Medicaid programs, as well community resources and services available to dual-eligible beneficiaries
• Strong interpersonal and communication skills to effectively engage with members, families, and healthcare providers
• Ability to manage multiple cases and priorities while maintaining attention to detail
• Adhere to code of ethics that aligns with professional practice
• Awareness of and sensitivity to the diverse backgrounds and needs of the populations served
• Decision making and problem-solving skills

Licensure and Certification

• Current, unrestricted clinical license in state of practice as a Registered Nurse, Social Worker or Clinical Counselor required
• Licensure may be required in multiple states as applicable based on State requirement of the work assigned
• Case Management Certification is highly preferred
• Must have valid driver's license, vehicle and verifiable insurance. Employment in this position is conditional pending successful clearance of a driver's license record check. If the driver's license record results are unacceptable, the offer will be withdrawn or, if employee has started employment in position, employment in this position will be terminated
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