MSHO Care Coordinator- South MN

Kids for the Future; Minneapolis (MN); Hybrid; USD 68,000 - 94,000; Full time

Job summary

Kids for the Future in Minneapolis, MN is seeking a Care Coordinator to provide comprehensive, person-centered care coordination for elderly and dual-eligible individuals under the MSHO program. The role includes assessments, care plans, service coordination, and ensuring CMS and DHS compliance.

Hybrid role with travel to member homes and facilities; requires a valid driver’s license and strong teamwork with interdisciplinary staff.

Qualifications

• Proficiency with clinical documentation tools such as Happian and Microsoft Office.
• Motivational interviewing and cultural competency required.
• Valid driver’s license and reliable transportation for in-home visits.
• Mandated reporter.

Responsibilities

• Provides comprehensive assessment or screening of each member’s social, medical and environmental safety needs.
• Conducts required in person and telephonic visits on a timely basis.
• Performs review of medical records in the appropriate EMR.
• Develops Person Centered Care Plans based on assessment requirements, maximizing self-determination and member choice of services, providers, and living arrangements.
• Incorporates interdisciplinary, holistic, and preventive care across all settings per CMS timeline.
• Provides culturally appropriate care.
• Communicates care needs and plan of care with members and/or representatives, primary physicians, and interdisciplinary team members.
• Contacts hospital, nursing facility, foster care or assisted living settings to share/obtain information for appropriate discharge.
• Communicates with service providers and members while arranging/authorizing services and addressing denials.
• Interdisciplinary collaboration with population health team for complex medical needs.

Skills

Motivational interviewing

Cultural competency

In-home visits

Driver's license

Mandated reporter

Tools

Happian

Microsoft Office

Job description

• Location 3433 BROADWAY ST NE,STE 300,Minneapolis, MN, 55413,United States
• Base Pay $68,000.00 - $94,000.00 / Year
• Employee Type FT Exempt
• Manage Others No

Contact information

• Name Human Resources
• Phone [phone]

Description

Position Summary: The MSHO (Minnesota Senior Health Options) Care Coordinator provides comprehensive, person-centered care coordination for elderly and dual-eligible individuals. This includes completing assessments, developing support plans, coordinating services, managing care transitions, and ensuring all activities are performed in compliance with CMS, DHS, and health plan requirements. The Care Coordinator applies clinical and psychosocial knowledge to advocate for the health, safety, and quality of life of members across settings. Responsible for delivery of care management in the long-term care and community setting as delegated in subcontracts with health plans which are contracted with CMS and DHS. Follow and uphold the Mission of Genevive.

Qualifications

• Proficiency with clinical documentation tools , Happian , and Microsoft Office tools .
• Motivational interviewing and cultural competency required .
• Valid driver’s license, reliable transportation, and ability to conduct in-home visits.
• Mandated reporter

Essential Functions

• Provides comprehensive assessment or screening of each member’s social, medical and environmental safety needs. Documents information in a timely manner on appropriate forms.
• Conducts required in person and telephonic visits on a timely basis.
• Performs review of medical records in the appropriate EMR.
• Develops Person Centered Care Plans based on assessment requirements, maximizing the level of self-determination and member choice of services, service providers, and living arrangements to meet identified needs. This includes disease management, advance directive planning, and vaccination updates.
• Incorporates interdisciplinary, holistic, and preventive care across all settings of care per CMS timeline.
• Provides culturally appropriate care.
• Communicates care needs and plan of care with members and/or member representatives, primary physicians, and interdisciplinary team members through written and/or verbal communication.
• Contacts appropriate personnel in hospital, nursing facility, foster care or assisted living settings to share and obtain necessary information that will facilitate discharge of the member to the appropriate level of care.
• Communicates with service providers and members while assisting with arrangement and authorization of services and issue denials of inappropriate services in a timely manner.
• Interdisciplinary collaboration with population health team when members have complex medical needs.

Physical/Mental Demands and Work Environment

• Hybrid role with regular travel to member homes, nursing facilities, assisted living, and community settings.
• Frequent in-person contact with members in uncontrolled environments (e.g., homes, facilities).
• Personal, reliable vehicle required ; must maintain valid driver’s license and insurance.
• Remote work involves prolonged sitting, screen use, virtual meetings, and documentation.
• Requires a professional, distraction-free home workspace, with reliable and secure internet access.
• Must adhere to organizational data security and privacy standards for handling sensitive PHI- HIPPA.
• Standard office equipment is used, including a computer, headset, printer, scanner, telephone, and web-based fax systems.
• Occasional lifting or movement of items (e.g., reports, files, small office equipment) up to 25 lbs.
• Must work independently, manage multiple complex tasks, and prioritize competing demands.
• Requires high productivity, attention to detail, and clinical decision-making with limited or evolving information.
• Must demonstrate emotional resilience and professionalism during sensitive or high-impact situations (e.g., unsafe housing, behavioral health issues).

Requirements

This role will manage a caseload in Lakeville, Apple Valley, Hastings, and Burnsville area.