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Clinical Care Coordinator
2 months ago
Position Overview
The Clinical Care Coordinator is responsible for the development, facilitation, monitoring, and communication of a comprehensive care strategy in collaboration with the member, their family or significant other, primary caregiver, attending physicians, and various healthcare providers. By utilizing assessments and interviews conducted by the Assessment Nurse, the Clinical Care Coordinator identifies risk factors, strengths, challenges, and service requirements of the member, ensuring their safety and well-being within their community.
Job Responsibilities
- Assess and analyze the evaluation and UAS data for members within the MLTC and MAP sectors.
- Establish a collaborative relationship with the Primary Care Provider (PCP) to facilitate discussions regarding the member's care.
- Review assessment outcomes with the PCP to highlight any issues not previously identified by the clinical team.
- Determine risk factors and categorize the member accordingly.
- As part of the Care Management team, formulate a detailed care plan encompassing all necessary services for the member, including a disaster preparedness plan.
- Conduct monthly monitoring of all members, primarily through telephone communication, with face-to-face interactions as needed.
- Identify clinical concerns that necessitate immediate assessment or treatment to mitigate the risk of avoidable hospitalizations, emergency department visits, or nursing home placements.
- Seek opportunities to enhance the quality of care by ensuring members receive essential preventive and chronic disease management.
- Pre-approve requests for additional services based on assessments and evidence-based standards, referring any denials, reductions, or limitations to the Medical Director.
- Assist members in coordinating services both within and outside of networks as appropriate, including facilitating discharges from acute and alternative care settings.
- Provide Care Coordination throughout the continuum of care.
- Enhance both the quality of care and the quality of life for MetroPlusHealth members.
- Collaborate with the Utilization Management (UM) department on concurrent and retrospective reviews.
- Follow up with assigned nursing staff for clinical updates to the care plan.
- Document coordination notes and routine member contacts within two business days, according to the assigned risk level.
- Engage in team care planning meetings.
- Address complaints that can be resolved within a single day.
- Support Customer Service and the UM department by providing necessary records and materials for grievances from MLTC/MAP program members.
- Communicate with members who are behind on their spend-down payments.
- Collaborate with all departments within MetroPlusHealth.
- Identify members suitable for specialty programs.
- Conduct all MLTC/MAP management activities in compliance with regulatory agency requirements.
- Provide information for all requests from the Quality Management Department for review by various Quality committees.
- Complete all other tasks assigned by MLTC Department Leadership.
- Participate in the department's on-call schedule, which is rotated among the care team.
Minimum Qualifications
- Bachelor's Degree required; BSN preferred.
- Two (2) to three (3) years of clinical experience in a certified home health agency (CHHA), Lombardi program, and/or MLTC or MAP program.
- Active New York State License as a Registered Nurse.
Professional Skills
- Integrity and Trust.
- Customer Service Orientation.
- Technical and Functional Skills.
- Effective Written and Oral Communication.
