| Duties: |
The primary purpose of the job is to: The Care Coordinator (RN/SW) assists members appropriate for care coordination services in achieving their optimal level of health. The Care Coordinator (RN/SW) must have relevant experience and education to work with Enrollees with complex health, behavioral health, long-term services and supports and/or psychosocial needs and perform the following functions: 1. Support an on-going Person-Centered Planning Process 2. Assess clinical risk and needs by conducting an assessment process that includes an Initial Screening, a Level I Assessment, and completion of or referral for a Level II Assessment (as appropriate); 3. Facilitate timely access to primary care, specialty care, LTSS, BH, SUD, and I/DD services, medications, and other health services needed by the Enrollee, including referrals to address any physical or cognitive barriers or referrals to the PIHP 4. Create and maintain an ICBR for each Enrollee to manage communication and information regarding referrals, transitions, and care delivery 5. Facilitate communication among the Enrollee's providers through the use of the Care Coordination Platform and other methods of communication including secure e-mail, fax, telephone, and written correspondence 6. Notify ICT of the Enrollee's hospitalization (psychiatric or acute), and coordinate a discharge plan if applicable; 7. Facilitate face-to-face meetings, conference calls, and other activities of the ICT as needed or requested by the Enrollee; 8. Facilitate direct communication between the provider and the Enrollee or the Enrollee's authorized representative and/or family or informal supports as appropriate 9. Facilitate Enrollee and family education 10. Coordinate and communicate, as applicable, with the PIHP Supports Coordinator and/or the LTSS Supports Coordinator to ensure timely, non-duplicative supports and services are provided; 11. Develop, with the Enrollee and ICT, following the Person-Centered Planning Process, an IICSP specific to individual needs and preferences, and monitor and update the plan at least annually or following a significant change in needs or other factors; 12. Coordinate and make referrals to community resources (e.g. housing, home delivered meals, energy assistance programs) to meet IICSP goals; 13. Perform ongoing Care Coordination 14. Monitor the implementation of the IICSP with the Enrollee, including facilitating the Enrollee's evaluation of the process, progress and outcomes and identifying barriers and facilitate problem resolution and follow-up. 15. Advocate with or on behalf of the Enrollee as needed, to ensure successful implementation of the IICSP 16. Support transitions in care when the Enrollee moves between care settings including 17. Conducts medication review, including reconciliation during transitions of care setting; 18. Provides access to a single point of contact for all questions or inquiries; 19. Provides disease self-management and coaching; 20. Providess periodic monitoring of health, functional and mental status along with pain and fall screening; 21. Ensures the provision of services in the least restrictive setting and transition support across and between specialties and care settings; 22. Connects Enrollees to services that promote community living and help to delay or avoid nursing facility placement; 23. Collaborates with nursing facilities to promote adoption of evidence-based interventions to reduce avoidable hospitalization, management of chronic conditions, medication optimization, fall and pressure ulcer prevention, and the coordination of services beyond the scope of the nursing facility benefit. |
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All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.