The care coordinator is responsible for promoting interdependent collaboration for member's continuum of care with the member, physician/primary care manager, family, nursing facility and other members of the care coordination team. The Care Coordinator is responsible for assessing the member's potential for and interest in transitioning from institutional facility care to home and community-based services care. This position is field based and requires travel to conduct face-to-face assessments with members.
Job Duties & Responsibilities
Collect in-depth information to identify members at risk for high cost medical care and develop a comprehensive personal plan of care for the individuals that will address those needs.
Conduct thorough and objective face-to-face assessments of the member to determine current status and needs, including physical, behavioral, functional, psychosocial, and financial, and health status expectation.
Assess clinical information to develop individualized plans of care for members.
Identify members with the potential for high risk complications and coordinate the appropriate treatment in conjunction with the member and care coordination team.
Conduct a thorough and objective face-to-face assessment of members residing in an institutional setting to determine current status and needs, including whether the member has the potential for and interest in transitioning from institutional care to home and community-based care.
Compare member's plan of care to establish pathways to determine variances and then intervene as indicated.
The care coordinator will determine specific objectives, goals, and actions as identified through the assessment process. The plan of care will be action oriented and time specific. Those duties include:
Assess clinical information to develop an individualized transition plan that will address all the services necessary to safely transition the member to the community, including, but not limited to, member needs related to housing, transportation, availability of caregivers, and other transition needs and supports.
Facilitate and execute specific interventions that will lead to accomplishing the goals established in the plan of care to ensure the member's health, safety, and welfare, and as applicable, to delay or prevent the need for more expensive institutional placement. Those duties include:
ct as an advocate for an individual's health care needs by identifying and communicating any barriers to a safe transition and strategies to overcome those barriers.
Act as an advocate for an individual's health care needs by identifying and communicating opportunities for care intervention, including identifying and addressing gaps in care.
Develop and implement targeted strategies to improve health, functional, or quality of life outcomes, such as disease management or pharmacy management.
Proactively educate members about the program, including opportunities for consumer direction of HCBS, and obtain necessary consents for participation.
Organize, integrate, and modify the resources necessary to accomplish the goals established in the plan of care.
Coordinate with institutional facilities as necessary to facilitate access to physical health and/or behavioral health services needed by the member and to help ensure the proper management of the member's acute and/or chronic physical health or behavioral health conditions.
Serve as a point of contact for coordination of all physical health, behavioral health, and other home and community based services.
Coordinate with the Fiscal Employer Agent (FEA) as needed.
Coordinate with member's primary care provider, specialists, and other providers and care programs to ensure comprehensive, holistic, person-centered approach to care.
Gather sufficient information from all relevant sources in order to determine the effectiveness of the plan of care. Those duties include:
Monitor and ensure that provision of covered physical health, behavioral health, and/or home and community based services are provided as a cost-effective alternative.
Management of critical transitions, such as hospital discharge planning.
Provide assistance in resolving concerns about service delivery or providers.
Routinely assess and monitor member's status, needs, and progress; if progress is static or regressive, determine reason and proactively encourage appropriate adjustments in their plan of care, providers and/or services to promote better outcomes.
Utilize criteria for authorizing appropriate home and community based services, obtain authorization for those services, and confirm that services are being provided and that members' needs are being met.
At appropriate and repeated intervals, the care coordinator will determine the plan of care's effectiveness in reaching desired outcomes and goals. This process might lead to a modification or change in the plan of care in its entirety or in any of its component parts.
Conduct, review, and revise, as necessary, member's risk assessment and risk agreement.
Maintain appropriate and ongoing communications and collaborations with members, their authorized representatives, physicians and health team members, and payer representatives.
Report quantifiable impact, quality of care, and/or quality of life improvements as measured against the care coordination goals.
Conducts face-to-face visits in the member's residence within the first twenty-four (24) hours of transition from a nursing facility and monthly visits thereafter for ninety (90) days.
Provide members with education about the ability to use an advance directive.
Establish working relations with referral sources, community resources, and care providers.
The incumbent is responsible for covering Shelby county and possibly surrounding areas.
This position requires a 24 month commitment for a lateral move.
Registered Nurse with active license in the state of Tennessee or hold a license in the state of their residence if the state is participating in the Nurse Licensure Compact Law; or master's level Social Worker with active license in the state of Tennessee (LCSW, LMSW, or LAPSW).
Minimum of 5 years healthcare and minimum of 3 years clinical experience required.
Minimum of 3 years experience providing care coordination to persons receiving long-term care and/or home/community based services and an additional 2 years work experience in managed and/or long-term care settings, preferred.
Exceptional skills of independence, organization, communication, problem-solving, professional interaction, and human relation skills, as well as analytical skills required.
Ability to work within specified timeframe requirements
Basic PC computer skills required with emphasis on Microsoft Office applications preferred
Valid Driver's License
100% day travel required
Employee may be required to participate in Runzhimer Program (auto reimbursement plan)
BlueCross BlueShield of Tennessee - 13 months ago
BlueCross BlueShield of Tennessee (BCBST) is the oldest and largest not-for-profit managed care provider in the state of Tennessee....