Care Coordinator for Long-term Care

1 month ago

Charleston, West Virginia, United States Highmark Health Full time

Job Summary

This is a full-time community-based position requiring frequent travel within the assigned territory in Delaware. The incumbent will travel to members' homes, nursing facilities, and other community-based settings to coordinate care needs across various service delivery systems and community supports.

Key Responsibilities

  • Travel to members' homes, nursing facilities, and other community-based settings to conduct face-to-face needs assessments and subsequent telephonic contact with members.
  • Assess, plan, coordinate, implement, and evaluate care for eligible members with chronic and complex healthcare, social service, and custodial needs.
  • Coordinate care across the continuum of services, assisting members with physical, behavioral, long-term services and supports (LTSS), social, and psychosocial needs in the safest, least restrictive way possible.
  • Facilitate authorization, coordination, continuity, and appropriateness of care and services in community or HCBS settings.
  • Facilitate transitions to alternate care settings, such as hospital to home, nursing facility to community setting, using an integrated care team to address members' specific needs.
  • Educate members or caregivers regarding healthcare needs, available benefits, resources, and services, including options for long-term care community or facility-based service delivery.
  • Provide education, resources, and assistance to help members achieve goals outlined in their plan of care and overcome obstacles to achieving optimal care in the least restrictive environment.
  • Develop a plan of care in conjunction with members or caregivers to identify services to meet members' specific needs and goals.
  • 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.
  • Collaborate with members' healthcare and service delivery teams, including the DSHP Plus LTSS Member Advocate, ICT, and discharge planners, to coordinate care needs and community resources for members.
  • Assist members in developing, implementing, and amending a back-up plan for gaps in provider coverage.
  • Ensure approved support services are being provided as outlined in the plan of care.
  • Evaluate the effectiveness of the service plan and make appropriate revisions as needed in accordance with policy and procedures and state contractual requirements.
  • Assist members in overcoming obstacles to optimal care through connection with community resources, including communicating with providers and formulating an appropriate action plan.
  • 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.

Qualifications

Required

  • Bachelor's degree in Social Work or in health, human, or education services and 3 years of experience in long-term care, home health, hospice, public health, or assisted living OR
  • Master's degree in Social Work or in health, human, or education services and 1 year of experience in long-term care, home health, hospice, public health, or assisted living OR
  • Registered Nurse or Licensed Practical Nurse and 2 years of experience in long-term care, home health, hospice, public health, or assisted living OR
  • A high school degree or equivalent and three years of qualifying experience with case management of the aged, including management of behavioral health conditions, or persons with physical or developmental disabilities, or HIV/AIDS population.

Substitutions

Preferred

  • One year in home clinical or case management experience
  • Certified Case Manager (CCM)
  • Licensed Bachelors Social Worker (LBSW)
  • Licensed Masters 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
  • Managed care experience

Skills

  • Working flexible hours to meet members' 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 home work space 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

Language (Other than English):

None

Travel Requirement:

25% - 50%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Works From Home

Teaches / trains others regularly

Occasionally

Travel regularly from the office to various work sites or from site-to-site

Occasionally

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required

Yes

Lifting: up to 10 pounds

Constantly

Lifting: 10 to 25 pounds

Occasionally

Lifting: 25 to 50 pounds

Rarely

Pay Range Minimum:

$57,700.00

Pay Range Maximum:

$106,700.00

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.

EEO is The Law

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled/Sexual Orientation/Gender Identity ()

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