Job Description

Care Coordinator – Enhanced Care Management and Community Support Services

Spanish / English bilingual a PLUS

Are you a Medical Assistant (MA), Certified Nursing Assistant (CNA), Community Social Worker, or Care Coordination expert? Ready for an office position? Star Nursing is hiring throughout Northern, Central, and Southern CA.

Position: Remote-Hybrid- in-person visits throughout the month
Hours: 9 am to 530 pm (PST)
Pay rate: $22 to $24/hr + milage reimbursement
Benefits: Health/Dental/Vision

Description:

The Care Coordinator works as part of the multi-disciplinary team, offering enhanced case management and other social services to adults who may have complex health conditions, are/have been homeless, and possibly have substance abuse issues. This is a Non-clinical position.

The Enhanced Care Manager works under the supervision of a clinical team of nurses and provides care management services to eligible Medi-Cal members. This position requires you to participate in the planning, development, implementation, and evaluation of services as per requirements and guidelines. Offering case management services to qualifying Medi-Cal members, focusing on community-based healthcare services. This includes creating care plans and formalized goal setting. Depending on the client’s needs, you may be required to accompany the member to appointments, schedule follow-up appointments, and assist with housing.

Enhanced Care Management program and Community Support services provide eligible Medi-Cal beneficiaries experiencing or at risk of homelessness with enhanced care management and coordination services. Enhanced Care Management coordinates a full range of physical health, behavioral health, and community-based services to ensure the individuals served have access to and receive the services necessary to address their complex medical needs and chronic conditions.

Responsibilities include:

• Connects with the Medi-Cal members via phone or in-person to facilitate engagement, assessment, follow-up
• Provide education/training visits to develop and address the Care Plan.
• Conducting initial assessments and periodic reassessments of client’s needs
• Leads the provision and coordination of services and direct services to the participants in your assigned caseload. (Caseload up to 50 members)
• Developing patient-focused care plans in partnership with other providers and the client
• Working with medical staff to develop, implement, and coordinate care plans for clients with chronic conditions such as diabetes, asthma, behavioral health conditions
• Advocate on behalf of Members with healthcare professionalism
• Responsible for driving a positive patient customer service experience through multiple support channels, including the patient portal, clinical platform, and messaging systems
• Respond to inquiries from patients and outside agencies and refer, when necessary, to the appropriate person or department
• Adhere to all organizational policies, HIPAA regulations, and company guidelines.
• Schedule weekly and monthly phone calls with members
• Monitor, document, and report changes in patient symptoms or behavior
• Monitor and maintain goal levels of calls per assigned caseload
• Capturing patient demographics information, insurance information, and structured data into patient management systems during each phone encounter
• Communicate to PCP any significant changes in patient concerns along with any updates on patient status
• Educate patients about health maintenance and disease prevention
• Completes all required documentation accurately, promptly, and thoroughly following department standards.
• Conducts initial and ongoing assessment of client’s health and/or support service needs. Sets the level of client need.
• Facilitates care transitions between providers, partners, referral sources, and specialty care providers.
• Follows up on referrals within established timeframes. (24 hrs once the referral is received)
• Facilitates enrollment of patients in specialty care and services.
• Schedules appointments and provides intakes per department guidelines and productivity goals.
• Ensure appropriate intake steps are followed, including eligibility, assessment of needs, collecting patient data, enrolling in programs, developing a care plan, and other steps as required by department guidelines.
• Provides basic and intensive individual support based on client needs. Support may include interventions, internal and community services referrals, and more intensive support, including a home visit.
• Tracks, monitors, and actively manages assigned patient cases to ensure care coordination, patient retention, and high utilization are monitored
• Performs other duties as assigned by team leads, supervisors, and managers.

Care Plan and Assessment Functions

• Complete assessments and develop care plans for the Medi-Cal member
• Review care plans routinely to ensure that appropriate care is being received.
• Ensure that monthly visit notes reflect the needs and goals of the member and that the member is following the care plan.
• Review patient care plans for appropriate goals, problems, approaches, and revisions based on patient-centered needs.

Patient Rights

• Maintain the confidentiality of all patient care information.
• Monitor care to ensure that all patients are treated fairly and with kindness, dignity, and respect.
• Report and investigate all allegations of patient abuse and/or misappropriation of property.

Qualifications:

• Previous experience in care/case management, counseling, or other health-related fields
• Compassionate and caring demeanor
• Ability to build rapport with clients.
• Strong leadership qualities
• Home office, ability to work independently
• Demonstrate effective leadership and management skills.
• Excellent written and verbal communication skills
• Have a strong relationship with referral sources
• Must be able to deal tactfully with personnel, patients, family members, visitors, government agencies/personnel, and the general public.
• Must be willing to seek out new methods and principles and incorporate them into existing practices.

Requirements

Required Experience:

• Execute and maintain confidential information according to HIPAA standards
• Possess a high level of tolerance and understanding for individuals with urgent and multiple case management and health needs
• Demonstrate strong skills in technology, including electronic health record systems and Microsoft Software office suites, and good knowledge of Excel, which is highly desired
• Exercise mature judgment and are highly motivated, self-starting, and proactive
• Are excellent at communicating in writing and verbally
• Have a strong sense of prioritization and can coordinate multiple demands in a high-pressure environment
• Ability to build rapport with patients
• Ability to communicate with patients from diverse backgrounds
• Strong problem-solving and critical-thinking skills
• Ability to work independently
• Bi-lingual in English and Spanish is a plus
• Working Knowledge of EMR systems
• Strong communication skills, verbal and written
• Experience and demonstration of strong customer service skills
• Excellent oral and written communication skills
• Basic working knowledge of insurance coverage, the insurance eligibility process
• Sensitivity to the needs and situations of multi-cultural populations from a variety of income levels
• Be able and willing to work flexible hours as needed, including evenings, weekends, and holidays
• Excellent attention to detail

Education/Experience:

• Medical Assistant (MA), Certified Nursing Assistant (CNA), Social Worker (SW), Sociology degree, associate degree Psychology, Pharmacy Tech, Medi-Cal specialist, etc. Preferred but not required.
• Minimum of one year of experience in a healthcare-related field or customer service
• Equivalent combination of education and experience that provides the skills, knowledge, and ability to perform the essential job duties and which meets any required state or federal certification requirements.
• Previous Care Management, Case Management, community support, or care coordination experience - Preferred

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