Care Coordinator – MSHO/MSC+ / Active, Unrestricted LSW or RN License required. Travel required throughout designated counties in Minnesota.

Full Job Description

Position Description

As the Care Coordinator – MSHO/MSC+, you will be responsible to coordinate services across the continuum of health care to meet the health and/or social service needs of members in Government plan products as assigned.Coordinate member services with appropriate primary care clinics/providers, care systems, specialists, clinic, county, and UCare personnel to achieve the most appropriate and cost-effective member care to optimize the long-term health of the member.

· Collaborate with treatment providers, county and community agencies, and contracted and non-contracted providers to identify and coordinate provision of health care services for Government plan product members. Appropriately apply care coordination criteria, protocols and procedures.

· Understand and accurately interpret and apply relevant contractual requirements, policies, procedures, and regulations for members which care coordination is a provided service.

· Collaborate with members and/or family members, primary care physicians, clinic staff, providers, and other relevant agencies to assure appropriateness of service that meets member needs and ensures desired outcomes.

· Complete in-person comprehensive assessment of assigned members.Appropriately utilize interpreter services as needed.Identify and monitor member needs, including needed preventive medical care, and significant changes in condition which may warrant early intervention for medical problems.Develop care plans to meet each member’s individual needs. Incorporate ethnic and culturally appropriate approaches to care planning.

· Present information on assigned members at assessment conferences and case reviews as appropriate.Enter member information in the clinical documentation system, GuidingCare software.Complete accurate, thorough, and timely required documentation.

· Meet and maintain all established caseload and performance metrics.

· Ensure safe transitions when members move from one setting to another (i.e. being discharged from a hospital or skilled nursing facility).Ensure the plan of care is communicated between the sending and receiving settings for both planned and unplanned transitions.Support members and member families through care transitions between various facilities, acute and/or chronic settings, and community-based living situations including home.

· Use appropriate communication tools per contractual and care model requirements.

· Monitor and report all quality-of-care issues through the appropriate internal or external systems.

· Assist with CMS Star Rating initiatives or HEDIS quality initiatives and project improvement planning as appropriate.

· Attend internal and external meetings, including staff meeting, discharge planning conferences, community meetings.

· Provide back-up coverage for other care coordinators as assigned.

· Must have reliable transportation to travel through designated counties in Minnesota.

· Other projects and duties as assigned.

Education

B.S. in nursing or B.A. in social work or a closely related field. Registered Nurse with a nursing diploma (3-year program) or associate degree in nursing with five or more years' experience also considered. Current and unrestricted Minnesota license as an RN is required or social worker is required. Licensure requirements may depend on assigned product(s).

Required Experience

Two year's experience in care coordination/case management across the continuum of health care (hospital, clinic, nursing home, home care etc.) with primary emphasis in working with complex social and medical problems.

MnCHOICES certifed assessor credential in place or with a plan to receive assessor credential within 3 months of hire date.

Preferred Experience

Managed care experience, experience with government programs, particularly Medicare, Medicaid and other State Public Programs. Experience working with multi-cultural populations desired.Bilingual in Hmong, Spanish, Russian, Somali or Vietnamese.