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.

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

Star Nursing remote jobs

Licensed Vocational Nurse (Remote)

Care Coordinator