Care Coordinator - Transition of Care

Care Coordinator - Transition of Care

Coordinate and collaborate with prison facilities in person. Knowledge of community resources that help support the incarcerated population. Coordinates care of individual clients with application to identified populations using assessment, care planning, implementation, coordination, monitoring, and evaluation for cost-effective and quality outcomes. Duties are typically performed during face-to-face home visits. Promotes the appropriate use of clinical and financial resources in order to improve the quality of care and member satisfaction. Assists with orientation and mentoring of new team members as appropriate. Provides care coordination to members with behavioral health conditions identified and assessed as requiring intensive interventions and oversight including multiple, clinical, social, and community resources. Conducts in-depth health risk assessment and/or comprehensive needs assessment which includes, but is not limited to psycho-social, physical, medical, behavioral, environmental, and financial parameters. Communicates and develops the care plan and serves as point of contact to ensure services are rendered appropriately, (i.e. during transition to home care, back up plans, community based services). Implements, coordinates, and monitors strategies for members and families to improve health and quality of life outcomes. Develops, documents, and implements a plan which provides appropriate resources to address social, physical, mental, emotional, spiritual, and supportive needs. Acts as an advocate for members care needs by identifying and addressing gaps in care. Performs ongoing monitoring of the plan of care to evaluate effectiveness. Measures the effectiveness of interventions as identified in the members care plan. Assesses and reviews plan of care regularly to identify gaps in care, trends to improve health and quality of life outcomes. Collects clinical path variance data that indicates potential areas for improvement of case and services provided. Works with members and the interdisciplinary care plan team to adjust plan of care, when necessary. Educates providers, supporting staff, members, and families regarding care coordination role and health strategies with a focus on a member-focused approach to care. Facilitates a team approach to the coordination and cost-effective delivery of quality care and services. Facilitates a team approach, including the Interdisciplinary Care Plan team, to ensure appropriate interventions, cost-effective delivery of quality care and services across the continuum. Collaborates with the interdisciplinary care plan team which may include member, caregivers, members legal representative, physician, care providers, and ancillary support services to address care issues, specific member needs, and disease processes whether, medical, behavioral, social, community-based, or long-term care services. Utilizes licensed care coordination staff as appropriate for complex cases. Provides assistance to members with questions and concerns regarding care, providers, or delivery system. Maintains professional relationships with external stakeholders, such as inpatient, outpatient, and community resources. Generates reports in accordance with care coordination goals.

The job duties listed above are representative and not intended to be all-inclusive of what may be expected of an employee assigned to this job. A leader may assign additional or other duties which would align with the intent of this job, without revision to the job description. Other job requirements:

• 3-5 years experience in Social Work, Nursing, or Healthcare-related field, or relevant experience in lieu of degree.
• Experience in utilization management, quality assurance, home or facility care, community health, long-term care, or occupational health required.
• Experience in analyzing trends based on decision support systems.
• Business management skills to include, but not limited to, cost/benefit analysis, negotiation, and cost containment.
• Knowledge of referral coordination to community and private/public resources.
• Requires detailed knowledge of cost-effective coordination of care in terms of what and how work is to be done as well as why it is done, this level includes interpretation of data.
• Ability to make decisions that require significant analysis and investigation with solutions requiring significant original thinking.
• Ability to determine appropriate courses of action in more complex situations that may not be addressed by existing policies or protocols.
• Decisions include such matters as changing in staffing levels, order in which work is done, and application of established procedures.
• Ability to maintain complete and accurate enrollee records.
• Effective verbal and written communication skills.
• Ability to work well with clinicians, hospital officials, and service agency contacts.

General job information:

Title: Care Coordinator - Transition of Care

Grade: 22

Work Experience - Required: Clinical, Quality

Work Experience - Preferred:

Education - Required: GED, High School Education

Education - Preferred: Associate, Bachelors

License and Certifications - Required: DL - Driver License, Valid In State

License and Certifications - Preferred: CCM - Certified Case Manager, LCSW - Licensed Clinical Social Worker, RN - Registered Nurse, State and/or Compact State Licensure

Salary Range: Salary Minimum: $50,225

Salary Maximum: $75,335

This information reflects the anticipated base salary range for this position based on current national data. Minimums and maximums may vary based on location. Actual pay will be adjusted based on an individuals skills, experience, education, and other job-related factors permitted by law. This position may be eligible for short-term incentives as well as a comprehensive benefits package.