Field Care Coordinator - Northern, VA Market

About the role

The Field Care Coordinator is responsible for facilitating, promoting, and advocating for the 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 patient 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. The Field Care Coordinator assists with care transitions, acts as a liaison between the Health Plan, the Commonwealth, enrollees, and their families, and follows professional standards, Commonwealth guidelines, and organizational policies.

This is a field-based position with a home-based office in the Northern, VA market. Candidates must reside within a commutable distance of Northern VA. Remote work flexibility is available for those in the Arlington, VA area, while hires in the Minneapolis or Washington, D.C. areas must work in the office at least four days per week.

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 represented and supported by the healthcare team.

Requirements

• Current and unrestricted Licensed Practical Nurse (LPN) license in the state of Virginia OR a 4-year degree in Social Work, Human Services, or a related field.
• 3+ years of care coordination, behavioral health experience, and/or work in a healthcare environment.
• 1+ years of experience with MS Office (Word, Excel, Outlook).
• Experience working with members who have medical needs, the elderly, individuals with physical disabilities, and/or those with communication barriers.
• Access to reliable transportation, a valid U.S. driver's license, and the ability to travel within the assigned territory to meet with members and providers.

Preferred Qualifications

• CCM (Certified Case Manager) certification.
• Experience working with Medicaid/Medicare populations.
• Experience in team-based care.
• Long-term care or geriatric experience.
• Background in Managed Care.

Physical Requirements

• Ability to transition between office and field locations multiple times per day.
• Ability to navigate multiple locations and terrains to visit members and providers.
• Ability to transport equipment (e.g., laptop, stethoscope) to and from field locations.
• Ability to remain stationary for extended periods for computer or tablet work.

Pay

The hourly pay for this role ranges from $24 to $43 per hour based on full-time employment, depending on factors such as local labor markets, education, work experience, and certifications.

Benefits

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