Medicaid Care Coordinator

Why Choose Jefferson Health Plans?

We are an award-winning, not-for-profit health maintenance organization offering Medicaid, Medicare, and Children’s Health Insurance Program (CHIP) plans that include special benefits to improve the health and wellness of our members.

We are committed to creating a community where everyone belongs, acknowledges, and celebrates diversity and has opportunities to grow to their fullest potential.

While this job currently provides a flexible remote option, due to in-office meetings, training as required, or other business needs, our employees are to be residents of PA or the nearby states of DE or NJ.

Perks of JHP and why you will love it here :

• Competitive Compensation Packages, including 401(k) Savings Plan with Company Match and Profit Sharing
• Flextime and Work-at-Home Options
• Benefits & Wellness Program including generous Time Off
• Impact on the communities we service We are seeking a talented and enthusiastic Care Coordinator to join our team!

Works with minimal supervision to ensure that comprehensive, patient- centered quality of care, cost effective patient care is offered for members in need of care coordination.

All care coordination follows NCQA standards for Complex Case Management (QI5), and based on evidence based guidelines. Review medication profiles, member history, verify appropriate testing, and facilitate office visits with primary care and specialist physicians for members targeted for care coordination services.

Coordinate with hospital and provider office case managers, as applicable, to ensure continuity of care and outpatient services when medically appropriate.

As the Medicaid Care Coordinator , your daily duties may include

• Able to work in a constant state of alertness and safe manner.
• Assumes primary responsibility for providing case management for identified members, including home, hospital and provider / community site visits as appropriate.
• Conduct timely telephonic outreach to members who have chronic conditions to improve health outcomes to include but not limited to :
• Assist primary care provider office(s) in coordinating care of members with complex
• medical needs; utilizing appropriate assessments in software.
• Coordinating care for members that is member focused, taking into account the members barriers to care and their personal goals.
• Documentation in software that includes capturing the member’s barriers to care, priority goals, plans of care and schedule for follow up.
• Applies knowledge of pathophysiology, psychosocial issues, confidentiality, ethical / legal issues, and therapeutic interventions and sources to assist the membership with problem-solving / decision-making that promotes health, improves level of functioning, and decreases inappropriate use of services.
• Educating members concerning their specific health care needs.
• Researching and coordinating care with available community resources.
• Researching and coordinating care with member’s behavioral health provider.
• Informing members about Health Partners Plans Medicaid benefits.
• Educates members on their specific health care needs and care options, including palliative care, as appropriate.
• Facilitates accommodations for members with language, communication, visual or mobility limitations.
• Provides approved educational materials that supports goals and interventions.
• Coordinate and collaborate care with external as well as internal Health Partners Plans resources to meet the individual needs of the member identified by the assessment and subsequent outreach;
• Assist primary care provider offices and specialist offices in coordinating care of members;
• Perform literature searches and follow up to date clinical guidelines in coordinating member care and services;
• Actively seek guidance from assigned Medical Director or designee as appropriate.
• Actively participate in multidisciplinary team meetings to represent care coordination program; Meetings include, but not limited to, Medical Director Rounds and CBH Collaborative Meeting.
• Collaborate with behavioral health MCOs and the member to develop, assist with implementation of, and follow up on interdisciplinary care plans for members with serious, persistent mental illness (SPMI).
• Work collaboratively within the Health Care Management department on tasks as needed;
• Refer appropriate cases to departments within Health Partners Plans to assist with quality of care and utilization management.
• Keep current on existing programs within the community as well as the needs of the population.
• Balances the dual roles of advocacy for the member and stewardship of fiscal resources by assisting the member to identify and utilize all available resources.
• Participates in multidisciplinary and interdepartmental collaboration, reporting and special projects as assigned.

Qualifications :

• Licensed Registered Nurse, or Licensed Practical Nurse, Licensed Social Worker or Social worker with at least 3 years of current clinical / case management experience,
• Active license to practice professionally in the Commonwealth of PA is required
• Experience including medical / surgical, home care, DME, authorizations, and case management is preferred.
• Bachelor’s Degree or above preferred
• CCM preferred upon hire or must obtain within 1 year of hire eligible. If not eligible for certification must be supervised by a certified case manager.

Skills We Value :

• Must present polished professional image.
• Understanding of HMO health care delivery systems.
• Ability to work and communicate effectively with co-workers, members, and providers.
• Must be organized, detailed oriented, and capable of handling multiple issues.
• Excellent telephone and verbal / written communication skills.
• Demonstrated functional ability in navigating company software programs and basic computer applications, including, but not limited to Microsoft Office suite.
30+ days ago