Field Care Coordinator (HIDE SNP) - Wayne County, MI and Surrounding (LIVONIA)

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The

Field Care Coordinator- HIDE SNP

is an essential element of an Integrated Care Model and is responsible for establishing a set of person-centered goal-oriented, culturally relevant, and logical steps to ensure that the person receiving LTSS receives services in a supportive, effective, efficient, timely and cost-effective manner. Care coordination includes case management, disease management, discharge planning, transition planning, and addressing social determinants of health and integration into the community.

This position is Field Based with a Home-Based office. The expected travel time for member home visits is typically 75% within a 50-mile radius and / or 50-minute drive from your home pending business needs.

If you reside in or near Wayne County, MI or surrounding area , you will have the flexibility to telecommute

• as you take on some tough challenges.

Primary Responsibilities :

Develop and implement care plan interventions throughout the continuum of care as a single point of contact

Communicate with all stakeholders the required health-related information to ensure quality coordinated care and services are provided expeditiously to all members

Advocate for persons and families as needed to ensure the patient's needs and choices are fully represented and supported by the health care team

Assess, plan, and implement care strategies that are individualized by the individual and directed toward the most appropriate, least restrictive level of care

Identifies problems / barriers to care and provide appropriate care management interventions

Identify and initiate referrals for social service programs, including financial, psychosocial, community and state supportive services

Provides resource support to members for local resources for services (e.g., Children with Special Health Care Services (CSHCS), employment, housing, independent living, foster care) based on service assessment and plans, as appropriate

Manage the person-centered