Field Care Coordinator - New Mexico

About the role

The Field Care Coordinator will be the primary care manager for a panel of members with low-to-medium complexity medical/behavioral needs. Care coordination activities will focus on supporting member's medical, behavioral, and socioeconomic needs to promote appropriate utilization of services and improved quality of care.

Responsibilities

• Engage members face-to-face and/or telephonically to complete a comprehensive needs assessment, including assessment of medical, behavioral, functional, cultural, and socioeconomic needs
• Develop and implement person centered care plans to address needs including management of chronic health conditions, health promotion and wellness, social determinants of health, medication management and member safety in alignment with evidence-based guidelines
• Partner and collaborate with internal care team, providers, and community resources/partners to implement care plan
• Provide education and coaching to support member self-management of care needs and lifestyle changes to promote health
• Support proactive discharge planning and manage/coordinate Care Transition following ER visit, inpatient or Skilled Nursing Facility (SNF) admission
• Advocate for members and families as needed to ensure the member's needs and choices are fully represented and supported by the health care team
• Create a positive experience and relationship with the member
• Practice cultural sensitivity and cultural competence in daily care
• Learn and listen to member needs and barriers to help promote self advocating
• Collaborate with clinical team of social aspects that might impact treatment plan
• Proactively engage the member to manage their own health and healthcare
• Conduct Comprehensive Needs Assessment (CNA)

Requirements

• Must meet one of the following:
• Bachelor's degree OR 2+ years of relevant health care experience
• 2-year degree or higher with 3+ years of clinical experience
• Current, unrestricted independent licensure as a Registered Nurse OR a Licensed Clinical Social Worker (LCSW), Licensed Master Social Worker (LMSW), Licensed Professional Clinical Mental Health Counselor, or Licensed Mental Health Counselor (LMHC) with 3 years of clinical experience
• 5+ years of relevant experience, including 3 years of clinical experience
• LPN with 3+ years of clinical experience
• 1+ years of experience with MS Office, including Word, Excel, and Outlook
• Driver's license and reliable transportation and the ability to travel up to 50% of the time within assigned territory to meet with members and providers
• Must have a designated workspace inside the home with access to high-speed internet availability
• Reside in New Mexico

Qualifications

• Certification as a Certified Case Manager (CCM)
• 1+ years of community case management experience coordinating care for individuals with complex needs
• Experience working in team-based care
• Background in Managed Care
• Reside in or within commutable driving distance to Albuquerque, Santa Fe, or Belin, NM

Skills

• Knowledge of community cultures and values

Benefits

• Comprehensive benefits package
• Incentive and recognition programs
• Equity stock purchase
• 401k contribution

Pay

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements).

Schedule

This position is full - time (40 hours / week) Monday - Friday. Employees are required to have flexibility to work any of our 8 - hour shift schedules during our normal business hours of 8am to 5pm. It may be necessary, given the business need, to work occasional overtime.

Location

This position is field - based position with a home - based office. You will work from home when not in the field. If you reside in or within commutable driving distance to Albuquerque, Santa Fe, or Belin, New Mexico or within a commutable distance, you will have the flexibility to work remotely*