The?Field Care Coordinator- HIDE SNP?is an essential element of an Integrated Care Model and is responsible for establishing a set of person-centered goal-oriented, culturally relevant, and logical steps to ensure that the person receiving LTSS receives services in a supportive, effective, efficient, timely and cost-effective manner. Care coordination includes case management, disease management, discharge planning, transition planning, and addressing social determinants of health and integration into the community.
This position is Field Based with a Home-Based office. The expected travel time for member home visits is typically 75% within a 50-mile radius and/or 50-minute drive from your home pending business needs.
If you reside in or near BerrienCounty, MI or surrounding area, you will have the flexibility to telecommute* as you take on some tough challenges.
Primary Responsibilities:
- Develop and implement care plan interventions 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 persons and families as needed to ensure the patient's needs and choices are fully represented and supported by the health care team
- Assess, plan, and implement care strategies that are individualized by the individual and directed toward the most appropriate, least restrictive level of care
- Identifies problems/barriers to care and provide appropriate care management interventions
- Identify and initiate referrals for social service programs, including financial, psychosocial, community and state supportive services
- Provides resource support to members for local resources for services (e.g., Children with Special Health Care Services (CSHCS), employment, housing, independent living, foster care) based on service assessment and plans, as appropriate
- Manage the person-centered service/support plan throughout the continuum of care
- Conduct home visits in coordination with the person and care team
- Conduct in-person visits, which may include nursing homes, assisted living, hospital or home
- Gathers, documents, and maintains all member information and care management activities to ensure compliance with current state and federal guidelines
