Care Coordination Specialist

2 weeks ago

Alameda, California, United States Alameda Alliance for Health Full time

KEY RESPONSIBILITIES:

Under the guidance of the Non-Clinical Supervisor in Case Management, the Health Navigator will assist members in navigating case management and disease management initiatives.

The Health Navigator will oversee a continuous caseload with assistance from clinical personnel as required.

This position emphasizes care coordination, offering both immediate and prolonged support to members seeking access to medically covered and non-covered services, which may include medical, social, behavioral, and community resources.


Core responsibilities encompass:
Identifying, reaching out to, and evaluating members who may gain from services.

Fostering and sustaining effective, ongoing relationships by facilitating communication and coordination with members, primary care providers, caregivers, and other parties involved in the member's care.

Identifying resources for member referrals based on ongoing needs.

Providing guidance, support, education, care coordination, and additional assistance to members and/or their families as they navigate the healthcare system.

Delivering support via telephone, email, or in-person interactions to participants, patients, and members in case and disease management programs to achieve their treatment/care plan objectives in collaboration with case managers when suitable.

Documenting care coordination and discharge planning requirements, activities, and follow-up actions promptly in accordance with organizational policies and regulatory standards within care management systems, both independently and in collaboration with case managers and other team members.

Participating in case conferences and meetings with case managers and medical directors to enhance effective care coordination.

Exhibiting a thorough understanding of coverage and benefits to promote appropriate service utilization while enhancing member knowledge and satisfaction.

Recognizing and promptly addressing continuity of care challenges or other issues.

Educating and responding to inquiries from members and/or their families regarding benefits, services, eligibility, and referrals with a positive and professional demeanor, fostering member satisfaction and retention.

Demonstrating a patient-centered approach to self-management skills while providing decision support, urgent care assistance, symptom management support, fundamental health and wellness information, and educational resources.

The navigator will collaborate with Enhanced Care Management (ECM) members enrolled in ECM alongside external ECM providers in accordance with Department of Health Care Services guidelines.

Identifying and facilitating appropriate community referrals for members, ensuring access to relevant support services, including medical and social resources to address presenting challenges and assist in overcoming barriers.

Assisting members in securing appointments and accessing suitable healthcare and community program services.

Initiating follow-up to confirm and coordinate additional member needs to support care coordination across various settings.

Collaborating positively in an interdisciplinary manner with other Case Managers, CM/DM staff, Medical Services, Provider Services, and Member Services departments, as well as community resources, to ensure the most suitable level of care and optimal outcomes.

Understanding and adhering to internal policies and procedures to ensure compliance with regulatory standards.

Recognizing when to escalate cases to a higher level of clinical support as necessary.

Maintaining an up-to-date knowledge base of desk-level procedures and training materials to meet regular productivity and quality standards.

Understanding and complying with expectations for each case type: care coordination, complex cases, transitions of care, etc. Completing additional duties and special projects as assigned.

PRODUCTIVITY:
Maintaining a caseload aligned with departmental requirements. Maintaining an adequate passing score on monthly productivity audits, including call volume and documentation volume. Demonstrating availability to accept incoming calls during designated hours unless prior approval from leadership is obtained.

QUALITY:
Achieving a satisfactory score on monthly audits.

ESSENTIAL FUNCTIONS OF THE ROLE

Telephone:
Completing and documenting all telephone interactions with members while explaining health plan program benefits. Describing the types of services offered by the organization and community partners.

Computer:
Accurately maintaining the member database to ensure data integrity.

Meetings:
Participating in departmental and non-departmental meetings and other scenarios. Performing writing, administration, data entry, analysis, and report preparation. Assisting case managers in communication and coordination with primary care providers, specialists, hospitals, and other providers on behalf of participants/patients/members. Adhering to the organization's Code of Conduct, regulatory and contractual requirements, and internal policies and procedures.

PHYSICAL REQUIREMENTS:
Engaging in constant and close visual work at a desk or computer. Sustaining constant sitting and desk work. Performing frequent data entry using a keyboard and mouse. Utilizing a telephone headset consistently. Engaging in frequent verbal and written communication with staff and other business associates via telephone, correspondence, or in person. Lifting folders, files, binders, and other objects weighing between 0 and 30 lbs. frequently. Walking and standing frequently.

MINIMUM QUALIFICATIONS:

EDUCATION OR TRAINING EQUIVALENT TO:
A Bachelor's degree or higher, or equivalent professional experience in a healthcare-related field is preferred. A cleared TB test is required prior to or within seven days of hire.

MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:

A minimum of three years of healthcare or customer service experience in the healthcare sector, preferably within a health plan environment, along with a working knowledge of medical and insurance terminology is preferred.

At least one year of experience in care delivery or coordination in an outpatient clinic, office, home care, or inpatient setting, including care plan development, care coordination, and discharge planning is preferred.

Knowledge of acute and chronic medical and behavioral health topics is desired.

SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):
Proficiency in English usage, grammar, and punctuation is required. Fluency in English is mandatory. Experience in a managed care organization or health plan is advantageous. Experience collaborating with case and disease managers or programs is beneficial. Experience interacting with physicians, physician offices, hospital discharge coordinators, and/or community-based programs is preferred. Strong analytical and interpretive skills are essential. Excellent organizational skills, proactivity, and attention to detail are necessary. Sensitivity to diverse, low-income communities is crucial. Exceptional critical thinking and problem-solving abilities are required. The ability to serve as a resource is important. Strong presentation, customer service, and delivery skills are essential. Familiarity with local resources is a plus.

Employees interacting with the public may be required to undergo Tuberculosis testing and be fully vaccinated against COVID-19 and influenza.

Successful candidates for these positions may be required to provide proof of vaccination against influenza and/or COVID-19, a negative Tuberculosis test, or request an exemption for qualifying medical or religious reasons during the onboarding process.

Candidates should not present proof of vaccination until instructed by the Human Resources department.

SALARY RANGE: $69,000 - $104,410.30 ANNUALLY
The organization is an equal opportunity employer and makes employment decisions based on qualifications and merit. We strive to have the best-qualified individuals in every role.

Our policy prohibits unlawful discrimination based on race, color, creed, gender, religion, veteran status, marital status, registered domestic partner status, age, national origin or ancestry, physical or mental disability, medical condition, genetic characteristic, sexual orientation, gender identity or expression, or any other consideration made unlawful by federal, state, or local laws.

M/F/Vets/Disabled.

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