Community Based Care Coordinator – Duals Integrated Care

Jobtailor; Taylor (MO); On-site; USD 70,000 - 95,000; Full time

Job summary

Jobtailor seeks a care coordination professional to manage dual-eligible Medicare/Medicaid beneficiary care. You will coordinate with physicians, social services, and community resources, developing and implementing individual care plans.

Responsibilities include leading interdisciplinary teams, educating members, and ensuring adherence to NCQA and CMSA standards. A nursing license or healthcare degree is required, with travel possible.

Qualifications

• Nursing degree or healthcare bachelor’s required.
• Unrestricted clinical license in practice state(s).
• Experience in discharge planning, case management or care coordination.

Responsibilities

• Manage and coordinate care for dual-eligible beneficiaries.
• Engage members in community settings and build care coordination relationships.
• Lead interdisciplinary care teams and advocate for beneficiaries.
• Develop individualized care plans and monitor adherence.

Skills

Care Coordination

Case Management

Discharge Planning

Interpersonal Skills

Education

Nursing degree

Healthcare bachelor's degree

Tools

Microsoft Office

Outlook

Word

Excel

Job description

• Manage and coordinate care for dual-eligible Medicare and Medicaid beneficiaries
• Engage members in community-based settings and establish care coordination relationships
• Liaise between healthcare providers, community resources, and beneficiaries
• Conduct comprehensive physical, mental, and social needs assessments
• Develop and implement individualized medical, social, and behavioral health care plans
• Lead and collaborate with interdisciplinary care teams
• Assist members with housing, transportation, food assistance, and social services
• Educate members and families about benefits, chronic conditions, medication adherence, and preventive care
• Monitor health status and care plan adherence and adjust plans as needed
• Follow up after hospitalizations and significant health events to support continuity and prevent readmissions
• Coordinate with physicians, specialists, community organizations, state agencies, and service providers
• Participate in care team meetings and address barriers to care
• Maintain accurate records of member interactions, care plans, and outcomes
• Collect and analyze data to evaluate care coordination effectiveness
• Advocate for beneficiary needs and preferences and empower members in healthcare decisions
• Evaluate member satisfaction and monitor concerns
• Conduct regular member, provider, and community-based visits
• Report abuse, neglect, or exploitation of older adults as a mandated reporter
• Perform assigned on-call responsibilities
• Adhere to NCQA and CMSA standards
• Perform other related duties as requested

Requirements

• 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 a health care profession required
• Experience in discharge planning, case management, care coordination, and/or home/community health management
• Current, unrestricted clinical license in the state of practice as a Registered Nurse, Social Worker, or Clinical Counselor required
• Licensure may be required in multiple states based on work assigned
• Valid driver's license, vehicle, and verifiable insurance required
• Successful driver's license record check required
• Annual Influenza vaccination required during Influenza season
• Intermediate proficiency with Microsoft Office, including Outlook, Word, and Excel
• Understanding of Medicare and Medicaid programs and community resources
• Strong interpersonal and communication skills
• Ability to manage multiple cases and priorities while maintaining attention to detail
• Adherence to professional code of ethics
• Awareness and sensitivity to diverse backgrounds and needs
• Decision-making and problem-solving skills
• Must reside in the assigned work territory
• May be required to travel greater than 50% of the time

Core Competencies

Demonstrates expertise in care coordination for dual-eligible Medicare and Medicaid beneficiaries, including conducting assessments, developing care plans, and collaborating with interdisciplinary teams. Proficient in managing multiple cases while adhering to ethical standards and understanding community resources.

Highest-signal resume keywords

• Registered Nurse License
• Care Coordination
• Case Management
• Discharge Planning
• Medicare and Medicaid Knowledge

Hard Skills

• Comprehensive Needs Assessment
• Individualized Care Plan Development
• Data Collection and Analysis
• Health Status Monitoring
• Community Resource Liaison

Soft Skills

• Interpersonal Skills
• Communication Skills
• Decision-Making Skills
• Problem-Solving Skills
• Attention to Detail

Certifications & Qualifications

• Nursing Degree
• Clinical License
• Annual Influenza Vaccination

Industry Keywords

• Dual-Eligible Beneficiaries
• Healthcare Providers
• Community-Based Settings
• Social Services
• NCQA Standards
• CMSA Standards

Tools & Technologies

• Microsoft Office
• Outlook
• Word
• Excel