LOCATION: Managed Care - 4896

SHIFT: 8:00AM to 4:00PM

Job Title Department

Community Based Social Work CountyCare Care Coordinator

Job Summary SEIU 73

The Community Based Social Work Care Coordinator (CBSWCC) supports the provision of care coordination in a manner that recognizes the Enrollee and the medical home care teams as essential partners in the Enrollee's care. These services are offered at the Enrollee's home, physician office, and/or other health care facilities. If it is determined the Enrollees care is medically complex the CBSWCC collaborates with a nurse in the provision care coordination. Completes assessments of complex health care needs and/or the presence of social determinants that impact the provision of care. Collaborates with Enrollee and medical home care team to develop and implement a care plan that mitigates barriers and links Enrollees of any risk levels to appropriate resources. The CBSWCC works across sites of care and with multiple disciplines to achieve the desired outcomes for the Enrollees.

Typical Duties

• Uses all available information sources to support care coordination activities-this may include portals, electronic medical records, claims data, plan information, utilization management information, and Milliman Care Guidelines (MCG).
• Completes screenings, assessments and care plan in accordance with contractual requirements and Care Coordination policy and procedure.
• Integrates information from claims review, notes, screenings, assessments and Medical Home teams in care plan.
• Tracks patient progress regarding goal achievement on the care plan.
• Updates documents based on Enrollee progress, changes in priorities, changes in health status or new information.
• Supports care coordination referrals from multiple sources including Enrollee request, plan referrals, medical home referrals, grievances, data reports or changes in risk score.
• Provides relevant education, counseling and support to assist member with the achievement of goals.
• Collaborates with Nurse Care Coordinators on patients with multiple co-morbidities, frequent hospitalizations or inappropriate Emergency Department (ED) visits.
• Interfaces with Medical Home team and Enrollee at prescribed or agreed upon intervals.
• Convenes the Interdisciplinary Care Teams, presents own patients, and provides guidance on others not directly managed.
• Conducts face to face visits on members with high or moderate risk stratifications on a quarterly basis.
• Conducts monthly outreach for high risk patients who are stable, more often for patients undergoing a transition or a change in treatment. Updates medical home team on status.
• Completes all required trainings, workshops, etc. within the required timeframe.
• Collaborates with medical home assignments to identify resources and process for effective communication.
• Conducts outreach to Case Management Department at hospital when Enrollees are admitted.
• Meets established case deadlines.
• Travels to the home of the Enrollees or their sites of care.
• Performs other duties as assigned.

• Medical, Dental, and Vision Coverage
• Basic Term Life Insurance
• Pension Plan
• Deferred Compensation Program
• Paid Holidays, Vacation, and Sick Time
• You may also qualify for the Public Service Loan Forgiveness Program (PSLF)

For further information on our excellent benefits package, please click on the following link: