Role Description
This position functions as a member of the interdisciplinary healthcare team in the provision of RN (Registered Nurse) Service Coordination Level 1 member care with the underlying objectives of enhancing the quality of clinical and financial outcomes and member satisfaction while managing the plan of care. Service Coordinator Level 1 is responsible for overall management of member's case within the scope of licensure; provides supervision and direction to non-RN clinicians participating in the member's case in accordance with applicable state law and contract; develops, monitors, evaluates, and revises the member's care plan to meet the member's needs, conducts additional assessments with the goal of optimizing member health care across the care continuum.
If you are located in Texas, you will have the flexibility to work remotely* as you take on some tough challenges.
Primary Responsibilities:
• Conducting telephonic or face-to-face holistic evaluations of Member's individual dynamic needs and preferences gathering relevant data and obtaining further information from Member/family.
• Identification, evaluation, coordination, and management of member's needs, including physical health, behavioral health, social services, and long-term services and supports.
• Provides education and support to Member/LAR on options of Consumer Directed, or Service-Related delivery models as applicable.
• Performs initial assessments and follow-up assessments and outreach calls within the time specified as part of contractual guidelines or per Member/family/provider request.
• Identifies members for high-risk complications and coordinates care with the member and the health care team.
• Manages members with chronic illnesses, co-morbidities, and/or disabilities, to ensure cost-effective and efficient utilization of health benefit.
• Assess, plan, and implement care strategies that are individualized for each member and directed toward the most appropriate, least restrictive level of care.
• Utilize both company and community-based resources to establish a safe and effective case management plan for members.
• Collaborate with member, family, and healthcare providers to develop an individualized plan of care.
• Identify and initiate referrals for social service programs, including financial, psychosocial, community, and state supportive services.
• Manage care plan throughout the continuum of care as a single point of contact.
• Communicate with all stakeholders the required health-related information to ensure quality coordinated care and services are provided expeditiously to all members.
• Advocate for patients and families as needed to ensure the patient’s needs and choices are fully represented and supported by the healthcare team.
• Utilize approved clinical criteria to assess and determine appropriate level of care for members.
• Document all member assessments, care plan, and referrals provided.
• Participate in Interdisciplinary team meetings and Utilization Management rounds and provide information to assist with safe transitions of care.
• Understand insurance products, benefits, coverage limitations, insurance, and governmental regulations as it applies to the health plan.
• Monitor services being delivered to ensure timeliness, appropriateness, and satisfaction in meeting Member needs.
• Reports medically complex cases to appropriate roles as necessary for review and problem solving.
• Maintains status on face-to-face and telephonic visit requirements for assigned Members.
Qualifications
• Knowledge of specific case management processes, and person-centered care practice.
• Excellent verbal and written communication skills.
• Analytical decision making and judgment skills.
• Demonstrated ability to function as a clinical care team leader.
• Knowledgeable of all clinical resources available to patients both inpatient and outpatient.
• Data Entry and Word Processing Skills.
Requirements
• Current unrestricted RN license in Texas, Graduate of an accredited school of nursing.
• 2+ years of experience in working with individuals with chronic illnesses, co-morbidities, and/or disabilities within a community health, clinical, hospital, acute care, direct care, or case management setting.
• 2+ years of experience working with MS Word, Excel, and Outlook.
• Bilingual - Spanish.
• Ability to travel in assigned region to visit Medicaid members in their homes and/or other settings, including community centers, hospitals, etc.
• Reliable transportation with valid driver’s license with good driving record.
Preferred Qualifications
• Bachelor’s Degree.
• CCM/RUG/PDPM Certified.
• 2+ years of experience working with Medicaid Waiver populations.
• 2+ years of experience working within the community health setting in a health care role.
• STAR+PLUS Service Coordination experience.
• Experience with electronic charting.
• Experience with arranging community resources.
• Field-based work experience.
• Behavioral Health experience.
• Proven background in managing populations with complex medical or behavioral needs.
Benefits
• Comprehensive benefits package.
• Incentive and recognition programs.
• Equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements).
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