Medical Care Coordinator for Delaware Residents

7 days ago

Dover, Delaware, United States CAI Full time
About the Role

We are seeking a skilled Medical Care Coordinator to join our team at CAI in Delaware. As a key member of our healthcare management team, you will be responsible for providing community-based care coordination and management for our clients in Delaware.

Job Summary

The successful candidate will provide medical care coordination services to our clients, conducting needs assessments, developing service plans, and facilitating access to healthcare services. You will work collaboratively with healthcare teams, educate clients and their families, and ensure high-quality, cost-effective care.

Duties and Responsibilities
  1. Travel to clients' homes, nursing facilities, and other community-based settings to complete face-to-face needs assessments with subsequent telephonic contact with the client in accordance with state and national guidelines, policies, procedures, and protocols.
  2. Assess, plan, coordinate, implement, and evaluate care for eligible clients with chronic and complex healthcare, social service, and custodial needs in a nursing facility or home and community-based care setting.
  3. Coordinate care across the continuum of services and assist clients' physical, behavioral, long-term services and supports (LTSS), social, and psychosocial needs in the safest, least restrictive way possible while considering the most cost-effective way to address those needs.
  4. Facilitate authorization, coordination, continuity, and appropriateness of care and services in community or HCBS.
  5. Facilitate transitions to alternate care settings such as hospital to home, nursing facility to community setting using an integrated care team to address the client's specific needs.
  6. Educate clients or caregivers regarding healthcare needs, available benefits, resources, and services including available options for long-term care community or facility-based service delivery.
  7. Provide education, resources, and assistance to help clients achieve goals as outlined in their plan of care and to overcome obstacles to achieving optimal care in the least restrictive environment.
  8. Develop a plan of care in conjunction with clients or caregivers to identify services to meet the client's specific needs and goals.
  9. Identify resources needed for a fully integrated care coordination approach including facilitating referrals to special programs such as Disease/Chronic Condition Management, Behavioral Health, and Complex Case Management.
  10. Collaborate with the client's healthcare and service delivery team including the DSHP Plus LTSS Member Advocate, ICT, and discharge planners, to coordinate the care needs and community resources for the client in order to maintain the client in the least restrictive safe environment possible.
  11. Assist clients in developing, implementing, and amending a back-up plan for gaps in provider coverage.
  12. Ensure approved support services are being provided as outlined in the plan of care. Evaluate the effectiveness of the service plan and making appropriate revisions as needed in accordance with per policy & procedures and state contractual requirements.
  13. Assist clients in overcoming obstacles to optimal care through connection with community resources, including communicating with providers and formulating an appropriate action plan.
  14. Document all case management services and intervention in the electronic health record. Adhere to all company, State, and Federal requirements related to privacy practices, HIPAA, and quality performance standards.
Requirements and Qualifications
  • Current Registered Nurse, licensed in the state of Delaware.
  • 5+ years of Case Management and Discharge Planning experience, including experience discharging members from a facility setting.
  • Experience completing Assessments, developing Service Plans and Care Plans.
  • Experience collaborating with PCPs, Occupational Therapists, Behavioral Health, and Providers.
  • Experience with ordering DME Equipment.
  • Experience educating and providing resources for the client's Social Determinants.
  • Working flexible hours to meet client needs.
  • Proficiency in PC-based word processing and database documentation (Word, Excel, Internet, Outlook).
  • Reliable transportation daily to be able to travel within assigned territory.
  • Ability to meet regulatory deadlines.
  • Has a dedicated workspace used only for business purposes and is able to comply with all telecommuter policies.
  • Experience in geriatric special needs, behavioral health, home health.
  • Understanding of the importance of cultural competency in addressing targeted populations.
  • Experience with electronic documentation system(s).
  • Experience with cost neutrality and budgeting.
  • Must be willing to travel throughout the state (may only need to travel 2-3 times a week depending on schedule).
  • Must be able to communicate clearly to clients - will be tasked with conducting assessments with clients over the phone.
Preferred Qualifications
  • Certified Case Manager (CCM).
  • Licensed Bachelor's Social Worker (LBSW).
  • Licensed Master's Social Worker (LMSW).
  • Licensed Clinical Social Worker (LCSW).
  • Experience working with HIV/AIDS population.
  • Experience working with behavioral health population.
  • Experience working with developmental disabilities population.
  • Medicare and Medicaid experience.
Physical Demands
  • Ability to safely and successfully perform the essential job functions consistent with the ADA and other federal, state, and local standards.
  • Ability to move about to accomplish tasks or move from one worksite to another.
  • Regularly access low and high spaces that may be at irregular angles such as under a desk.
  • Ability to conduct repetitive tasks on a computer, utilizing a mouse, keyboard, and monitor.
  • Must be able to communicate with customers/team members over the phone and in person.
  • Must be able to wear personal protective gear such as a helmet, goggles, mask, and protective footwear throughout the day.

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