Community Based Care Coordinator - Waiver

Job Summary :

The Community Based Care Coordinator, Duals Integrated Care is responsible for managing and coordinating care for dual-eligible beneficiaries, those who qualify for both Medicare and Medicaid. This position focuses on integrating health services and community resources to improve health outcomes and enhance the quality of life for individuals with complex health needs.

Essential Functions :

• Engage with the member in a variety of community-based settings to establish an effective, care coordination relationship, while considering the cultural and linguistic needs of each member.
• Function as a liaison between healthcare providers, community resources, and dual-eligible beneficiaries to ensure seamless communication and care transitions.
• Conduct comprehensive assessments to identify the physical, mental, and socials needs of dual-eligible individuals.
• Develop and implement individualized care plans based on unique needs of each member, considering their medical, social, and behavioral health requirements.
• Lead and collaborate with interdisciplinary care team (ICT) to create holistic care plans that address medical and non-medical needs.
• Assist members in accessing community resources, including housing, transportation, food assistance, and social services.
• Educate members about their benefits and available services under both Medicare and Medicaid.
• Provide education to members and their families about managing chronic conditions, medication adherence, and preventive care.
• Promote health lifestyle choices and self-management strategies.
• Regularly monitor member's health status and care plan adherence, adjusting, as necessary.
• Follow up with members after hospitalizations or significant health events to ensure continuity of care and prevent readmissions.
• Work closely with primary care physicians, specialists, and other healthcare providers to coordinate care and share relevant information.
• Coordinate with community-based organizations, other stakeholders / entities, state agencies, and other service providers to ensure coordination and avoid duplication of services.
• Participate in care team meetings to discuss member progress and address barriers to care.
• Maintain accurate and up-to-date records of members interactions, care plans, and outcomes.
• Collect and analyze data to evaluate the effectiveness of care coordination efforts and identify areas of improvement.
• Advocate for the needs and preferences of dual-eligible beneficiaries within the healthcare system.
• Empower members to take an active role in their healthcare decisions.
• Evaluate member satisfaction through open communication and monitoring of concerns or issues.
• Regular travel to conduct member, provider and community-based visits as needed and per the regulatory requirements of the program.
• Report abuse, neglect, or exploitation of older adults as a mandated reporter as required by State law.
• On-call responsibilities as assigned.
• Adherence to NCQA and CMSA standards.
• Performs any other job related duties as requested.

Education and Experience :

Competencies, Knowledge and Skills :

Licensure and Certification :

Working Conditions :

Will be exposed to weather conditions typical of the location and may be required to stand and / or sit for long periods of time.

Must reside in the same territory they are assigned to work in; exceptions may be considered, due to business need

May be required to travel greater than 50% of time to perform work duties.

Required to use general office equipment, such as a telephone, photocopier, fax machine, and computer

Flexible hours, including possible evenings and / or weekends as needed to serve the needs of our members

Compensation Range :

$61,500.00 - $98,400.00 CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type : Salary

Competencies :

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.

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