Field Care Coordinator - Northern, VA Market

Primary 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 members' needs and choices are fully represented and supported by the health care team

Required Qualifications

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

Preferred Qualifications

• CCM certification
• Experience working with Medicaid / Medicare population
• Experience working in team-based care
• Long term care / geriatric experience