Duals Integrated Care Navigator | Flexible Hours

CareSource; Oregon; Hybrid; USD 63,000 - 100,000; Full time

Job summary

CareSource in Oregon seeks a Community Based Care Coordinator, Duals Integrated Care to manage care for dual-eligible beneficiaries, coordinating health services with community resources to improve outcomes. The role emphasizes integrated care planning, multidisciplinary collaboration, and ongoing patient education.

You will engage with members in various settings, develop individualized plans, and monitor progress while traveling as needed to meet regulatory requirements.

Qualifications

• Nursing degree from an accredited nursing program required
• 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 (e.g. 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

Responsibilities

• Engage with members in community-based settings to build an effective care coordination relationship, honoring cultural and linguistic needs
• Serve as liaison between providers, community resources and dual-eligible beneficiaries to ensure seamless care transitions
• Conduct comprehensive assessments of physical, mental, and social needs of dual-eligible individuals
• Develop and implement individualized care plans based on medical, social and behavioral health requirements
• Lead the interdisciplinary care team to create holistic care plans addressing medical and non-medical needs
• Assist members in accessing housing, transportation, food assistance, and social services
• Educate members about benefits and services under Medicare and Medicaid
• Provide education to members and families on chronic condition management, medication adherence, and preventive care
• Promote healthy lifestyle choices and self-management strategies
• Monitor health status and adherence to care plans; adjust as needed
• Follow up after hospitalizations or significant health events to prevent readmissions
• Coordinate with primary care physicians, specialists, and other providers to share information
• Collaborate with community-based organizations and state agencies to avoid service duplication
• Participate in care team meetings to discuss progress and barriers
• Maintain accurate records of interactions, care plans, and outcomes
• Collect and analyze data to evaluate effectiveness of coordination efforts
• Advocate for the needs and preferences of dual-eligible beneficiaries
• Empower members to participate in their healthcare decisions
• Evaluate member satisfaction and address concerns
• Travel regularly to conduct member, provider and community visits as needed
• Report abuse, neglect, or exploitation as required by state law
• On-call responsibilities as assigned
• Adhere to NCQA and CMSA standards
• Performs other job-related duties as requested

Skills

Interpersonal communication

Microsoft Office

Care coordination

Dual-eligible population

Travel willingness

Education

Nursing degree

Bachelor's degree in health care

Job description

CareSource in Oregon seeks a Community Based Care Coordinator, Duals Integrated Care to manage care for dual-eligible beneficiaries, coordinating health services with community resources to improve outcomes. The role emphasizes integrated care planning, multidisciplinary collaboration, and ongoing patient education.

You will engage with members in various settings, develop individualized plans, and monitor progress while traveling as needed to meet regulatory requirements.