The Care Coordinator is responsible for coordination of services related to the delivery of medical benefits by following established benefit policies and guidelines for the treatment and evaluation of members of a specialized needs plan.
Performs daily review of inpatient Census to ensure members are receiving care and services in accordance with established clinical guidelines and in the most appropriate care setting.
Provides direction and support to Care Coordinator Assistants to ensure timely collection of data, ongoing provider and member outreach and documentation of outreach activities and outcomes.
Participates in the review of quality monitoring data of HIV, CD 4 and viral loads.
Coordinates access to other services such as home health care, durable medical equipment, pharmaceutical, vision, and family planning.
F/U with members and providers when a need is identified
Conducts Utilization Management determinations in accordance with Article 49- Utilization Review.
Ensures collection and review of required documentation such as HIV verification and audits
Reviews clinical documentation, claims/utilization data to ensure members are receiving appropriate care and implement strategies to address unmet needs as appropriate.
Provides direction and support to Care Coordinator Assistant to ensure timely collection of data, ongoing provider and member outreach and documentation of outreach activities and outcomes.
Conducts member/provider education including but not limited to prevention, health promotion, appropriate level of care/services specific to enrollees health status.
Ensures timely and accurate flow of information among the health services teams and other providers.
Participates in comprehensive, interdisciplinary care planning.
Identifies and advocates for structural and process changes needed at Program sites, the Plan, or In-Network Providers to improve quality of care and services to members.
Registered Nurse License
EXPERIENCES AND/OR SKILLS REQUIRED
Minimum of two (2) years of prior health care or managed care experience.
Minimum of two (2) years of HIV/AIDS, medical or chronic care experience.
Demonstrated knowledge of Article 49- Utilization Review process.
Demonstrated strong verbal/ written communication and customer service skills.
Demonstrated strong organizational, analytical and interpersonal skills with detail-oriented focus required.
Demonstrated computer proficiency, including but not limited to, Microsoft Office (Word, Excel, Access).
Bilingual, Spanish preferred.