Care Coordination Specialist
2 days ago
At Luminis Health, we are seeking a highly skilled Community Care Manager to join our team. As a key member of our care coordination team, you will play a vital role in ensuring that our patients receive high-quality, patient-centered care.
Job Summary:The Community Care Manager will work collaboratively with physicians, staff, and other healthcare professionals to provide care coordination and ensure that safety, best practices, and high-quality standards are maintained across the continuum. You will maintain knowledge of care management, behavioral health, social determinants of health, and chronic disease self-management resources available to patients and facilitate patients' adoption of supportive services.
Key Responsibilities:- Function as a team subject matter expert in identifying the social determinants of health and the optimal community resources to support high and rising risk patients in self-care management.
- Assist patients through the healthcare continuum as a patient advocate, navigator, and liaison to the team, providers, and/or community resources.
- Provide leadership to the team to improve care, community resource coordination, and manage the referral processes.
- Facilitate health and disease patient education and support patient self-management of disease and behavior modification interventions.
- Collaborate with patients, care team, and providers to understand patient short and long-term goals and contribute to patient longitudinal plan of care.
- Coordinate continuity of patient care with providers across the healthcare system, including post-hospital or ED discharge.
- Use high-risk screening criteria to identify and manage high-risk patients, including patients with multiple comorbidities or at risk of avoidable utilization/readmission.
- Participate on teams for data collection, health outcomes reporting, clinical audits, and programmatic evaluations related to the Maryland Primary Care Program (MDPCP), and quality improvement initiatives.
- Evaluate the psycho-social clinical plan of care, resource utilization, and contribute to the development of new tools, forms, and procedures.
- Contribute to the performance evaluation of team members.
- Master's degree with a focus in social work. LCSW-C required (or obtained within 6 months of employment).
- At least 5 years of experience in healthcare with care management experience.
- Required License/Certification: Licensed Certified Social Worker (LCSW) or Licensed Certified Social Worker Clinical (LCSW-C) from the Maryland Board of Social Work Examiners or other approved designated Social Worker license/certification. If Licensed Certified Social Worker (LCSW), must obtain Licensed Certified Social Worker Clinical (LCSW-C) within 6 months of hire.
- Current American Health Association Health Care Provider Basic Life Support (BLS) CPR certification.
- Case Management Certification strongly preferred.
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