Field Care Coordinator - Arlington, VA and surrounding areas

About the role

The Field Care Coordinator facilitates, promotes, and advocates for enrollees' ongoing self-sufficiency and independence. This position assesses and plans for an identified group of patients, evaluates the availability of natural supports (e.g., family members), and collaborates with the Interdisciplinary Team to coordinate comprehensive, efficient, and cost-effective care. The role involves traveling to enrollees' homes, nursing facilities, Adult Day Health centers, and Adult Living Facilities (ALF) to conduct in-depth assessments and develop care plans. Field Care Coordinators assist with care transitions, act as liaisons between the Health Plan, the Commonwealth, enrollees, and their families, and adhere to professional standards, Commonwealth guidelines, and organizational policies. This is a field-based position with a home-based office, requiring residence within a commutable distance of the Northern VA markets.

Responsibilities

• Engage members face-to-face and/or telephonically to complete a comprehensive needs assessment, including medical, behavioral, functional, cultural, and socioeconomic needs.
• Develop and implement person-centered care plans addressing chronic health conditions, health promotion, social determinants of health, medication management, and member safety, aligned with evidence-based guidelines.
• Partner and collaborate with internal care teams, providers, and community resources to implement care plans.
• Provide education and coaching to support member self-management of care needs and lifestyle changes.
• Support proactive discharge planning and manage/coordinate care transitions following ER visits, inpatient stays, or Skilled Nursing Facility (SNF) admissions.
• Advocate for members and families to ensure their needs and choices are fully represented and supported by the healthcare team.

Requirements

• Bachelor's degree in a health or human services field.
• 1+ years of experience working directly with individuals who receive Long-Term Services and Supports (LTSS).
• 1+ years of experience with MS Office (Word, Excel, Outlook).
• 1+ years of experience working with members who have medical needs, the elderly, individuals with physical disabilities, or those with communication barriers.
• Ability to travel 50% within Northern VA, with access to reliable transportation and a valid US driver's license.
• Must reside within a commutable distance of the Northern VA markets.

Preferred Qualifications

• CCM, ACM, or QMHP certification.
• Experience working with Medicaid/Medicare populations.
• Experience in team-based care or long-term care/geriatric settings.
• Background in Managed Care.
• Licensure as a Licensed Mental Health Professional (LMHP), Registered Nurse/Licensed Practical Nurse (RN/LPN), Qualified Mental Health Professional (QMHP), Licensed Master's Social Worker (LMSW), Licensed Bachelor's Level Social Worker (LBSW), Master's Level Social Worker (MSW), or Bachelor of Social Work (BSW).
• 3+ years of care coordination, behavioral health experience, and/or work in a healthcare environment.

Pay

The hourly pay for this role ranges from $24.00 to $43.00 per hour based on full-time employment, determined by factors such as local labor markets, education, work experience, and certifications.

Benefits

• Comprehensive benefits package (eligibility requirements apply).
• Incentive and recognition programs.
• Equity stock purchase and 401k contribution.