Field Care Coordinator - Winchester, Frederick County, and Clarke County, VA

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, ensuring the availability of natural supports such as family members. The Field Care Coordinator collaborates with the Interdisciplinary Team to coordinate comprehensive, efficient, and cost-effective patient care.

This is a field-based position with a home-based office, requiring travel throughout Winchester, Clarke County, and Frederick County, VA, and surrounding areas to conduct in-depth assessments and develop care plans in enrollees' homes, nursing facilities, Adult Day Health, and Adult Living Facilities (ALF). The role involves assisting enrollees with care transitions and acting as a liaison between the Health Plan, the Commonwealth, enrollees, and their families.

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 to address needs such as chronic health condition management, 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, 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 Social Work or Human Services (or related field).
• 3+ years of care coordination, behavioral health experience, and/or work in a healthcare environment.
• 3+ years of experience working with members who have medical needs, the elderly, individuals with physical disabilities, and/or those with communication barriers.
• 1+ years of experience with MS Office, including Word, Excel, and Outlook.
• Access to reliable transportation and a valid US driver's license with the ability to travel within assigned territory.

Preferred Qualifications

• Current and unrestricted Licensed Practical Nurse in the state of Virginia.
• CCM certification.
• Experience working with Medicaid/Medicare populations.
• Experience working in team-based care.
• Long-term care/geriatric experience.
• Background in Managed Care.

Benefits

In addition to your salary, we offer a comprehensive benefits package, incentive and recognition programs, equity stock purchase, and 401k contribution (all benefits are subject to eligibility requirements).

Pay

The hourly pay for this role will range from $24 - $43 per hour based on full-time employment. We comply with all minimum wage laws as applicable.