Care Coach (Long-Term Services & Support)

About the role

Become a part of our caring community Humana Healthy Horizons in Virginia is looking for Care Coaches (Care Coach 1).

Responsibilities

• Assess and evaluate members' needs and requirements to achieve and/or maintain optimal wellness state by guiding members/families toward and facilitating interaction with resources appropriate for the care and wellbeing of members.
• Work assignments are often straightforward and of moderate complexity.
• Meet members in the field at their home, Nursing Facility (NF) or location of the member's choice, spend quality time assessing their goals, needs and barriers and then connect our members with quality services to promote their ultimate well-being and drive person centered health outcomes.
• Specialized support for Members receiving Long Term Services and Support (LTSS), with a focus on addressing health related social needs (HRSNs), providing psychosocial support, and ensuring LTSS meets the member's service needs.
• May support members residing in NFs by building relationships with facility staff, advocating for member care (including access to needed behavioral health services), and assessing the member's desire and ability to return to the community.
• Contact members telephonically and face-to-face to establish goals and priorities, evaluate resources, develop plans of care, and identify LTSS providers and community partnerships to provide a combination of services and supports that best meet the needs and goals of member and caregiver through person centered thinking approaches.
• Develop and modify Individual Service Plan and involve applicable members of the care team in care planning (Informal caregiver coach, PCP, etc.).
• Supports members through navigation of their LTSS and related environmental and social needs.
• Utilizes available information pertaining to member to prevent the need for administration of duplicative assessments.
• Facilitates interactions with other payer sources, providers, and Interdisciplinary Care Teams.
• Educates members in maintaining Medicaid eligibility.
• Aids in the entry of annual Level of Care assessment into state portal.

Requirements

• Must reside in the Central region of Virginia (Franklin City, Southampton, Sussex, Dinwiddie or surrounding counties)
• Bachelor's degree in health or human services field OR an active LPN license in the Commonwealth of Virginia without disciplinary action
• Two (2) years of prior experience in health care and/or case management
• One (1) year of experience working directly with individuals who meet the Cardinal Care Priority Population criteria (adults, pediatrics populations at risk for chronic medical conditions & high social needs)
• Intermediate to advanced computer skills and experience with Microsoft Word, Excel, and Outlook
• Ability to use a variety of electronic information applications/software programs including electronic medical records
• Exceptional oral and written communication and interpersonal skills with the ability to build rapport with internal and external customers and stakeholders
• Proven ability of critical thinking, organization and problem-solving skills
• This role is considered patient facing and is part of Humana's Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB.
• Ability to travel to region-based facilities and homes for face-to-face assessments and interactions with members and/or families
• This role is part of Humana's driver safety program and therefore requires an individual to have a valid state driver's license and are expected to maintain personal vehicle liability insurance
• Individual must carry vehicle insurance in accordance with their residing state minimum required limits, or $25,000 bodily injury per person/$25,000 bodily injury per event /$10,000 for property damage or whichever is higher

Preferred Qualifications

• Nursing home diversion or long-term care case management experience
• Experience with Medicare & Medicaid recipients
• Experience with electronic case note documentation and documenting in multiple computer applications/systems
• Experience working with complex health population
• Experience working with a Waiver Program
• Knowledge of community health and social service agencies and additional community resources
• Bilingual or Multilingual: English/Spanish, Arabic, Vietnamese, Amharic, Urdu or other - Must be able to speak, read and write in both languages without limitations and assistance