Job Summary:
The Community Based Transitions of Care Coordinator - Duals Integrated Care is responsible for managing and coordinating care for dual-eligible beneficiaries that have experienced a transition of care, this position focuses on following the beneficiary through the admission through post-discharge life cycle to ensure a smooth transition between health settings and/or home.
Essential Functions:
Function as a liaison between healthcare providers, community resources, and dual-eligible beneficiaries to ensure seamless communication and care transitions.
Contact beneficiary and admitting/discharging facility within the required timeframe when discovering a transition of care to coordinate care.
Conduct comprehensive assessments to identify the physical, mental, and socials needs of dual-eligible individuals that have experienced hospitalization/transition of care, while considering that assessments may warrant an in-person visit based on the beneficiary's needs.
Develop and implement individualized care plans based on unique needs of each transitioning member, considering their medical, social, and behavioral health requirements and relevant change in condition.
Coordinate with hospital discharge planners, either telephonically or onsite at the facility, to ensure safe transitions from the inpatient setting.
Ensure timely transfer of member's transition record/discharge instructions to provider.
Complete medication review and reconciliation within the required timeframe for all discharges.
Collaborate with interdisciplinary care team (ICT) to create holistic care plans that address medical and non-medical needs.
In collaboration with the Primary Care Coordinator, assist members in accessing community resources, including housing, transportation, food assistance, and social services.
Educate members about their transportation benefits to ensure transportation is not a barrier to completing their provider follow up visit within the required timeframe and assisting with arranging this as needed.
Provide education to members and their families about managing chronic conditions, medication adherence, and preventive care.
Promote health lifestyle choices and self-management strategies.
Monitor member's health status and care plan adherence, adjusting the care plan as necessary.
Follow up with members after an inpatient stay to ensure continuity of care and prevent readmissions.
Work closely with primary care physicians, specialists, and other healthcare providers to coordinate care and share relevant information.
Collaborate with healthcare team to discuss member progress and address barriers to care.
Maintain accurate and up-to-date records of members interactions, care plans, and outcomes.
Collect and analyze data to evaluate the effectiveness of care coordination efforts and identify areas of improvement.
Advocate for the needs and preferences of dual-eligible beneficiaries within the healthcare system.
Empower members to take an active role in their healthcare decisions.
Evaluate member satisfaction through open communication and monitoring of concerns or issues.
Travel as needed to conduct member, provider and community-based visits.
Report abuse, neglect, or exploitation of older adults as a mandated reporter as required by State law.
Adherence to NCQA and CMSA standards.
Perform any other job related duties as requested.
Education and Experience:
Associates degree in Nursing from an accredited nursing program required or
Bachelor's degree in healthcare or related field required
Previous experience in nursing (i.e. 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
Competencies, Knowledge and Skills:
Intermediate proficiency level with Microsoft Office, including Outlook, Word and Excel.
Understanding of Medicare and Medicaid programs, as well community resources and services available to dual-eligible beneficiaries.
Strong interpersonal and communication skills to effectively engage with members, families, and healthcare providers
Ability to manage multiple cases and priorities while maintaining attention to detail.
Adhere to code of ethics that aligns with professional practice.
Awareness of and sensitivity to the diverse backgrounds and needs of the populations served
Decision making and problem-solving skills.
Licensure and Certification:
Current unrestricted clinical license in state of practice as a Registered Nurse is required. Licensure may be required in multiple states as applicable based on State requirement of the work assigned.
Case Management Certification preferred
Must have valid driver's license, vehicle and verifiable insurance. Employment in this position is conditional pending successful clearance of a driver's license record check. If the driver's license record results are unacceptable, the offer will be withdrawn or, if employee has started employment in position, employment in this position will be terminated
To help protect our employees, members, and the communities we serve from acquiring communicable diseases, Influenza vaccination is a requirement of this position. CareSource requires annual proof of Influenza vaccination for designated positions during Influenza season (October 1 - March 31) as a... For full info follow application link.
CareSource is an equal opportunity employer and gives consideration for employment to qualified applicants without regard to race, color, religion, sex, age, national origin, disability, sexual orientation, gender identity, genetic information, protected veteran status or any other characteristic protected by applicable federal, state or local law.
