Senior Care Coordinator

024450 Clin Alli-Care Management

Position Summary:

As part of the care management dyad, the Care Coordinator works directly with assigned CCA members to help them navigate the health care system, ensures the members know how to get services and answers member questions on obtaining needed care. The Care Coordinator communicates with members, via the method, mechanism and cadence that works best for each member, including in-person visits, to provide engagement, promote establishment of trust, and ensure responsiveness to concerns and questions.

The Care Coordinator is responsible for assisting members in creating a member-centered care plan and helping members access a broad base of support in the care team to advance their goals for independent living, recovery, and community connection.

This position requires in person visits to members in their homes and will support members across various locations

Supervision Exercised:

• No, this position does not have direct reports. 

Essential Duties & Responsibilities:

• Maintains open lines of communication with CCA members and interact with members as needed, based on member preference and care plan recommendations
• Primary resource for members regarding health care benefits
• Collaborates with community-based PCPs/ Specialists, as needed.
• Ensures members have an interdisciplinary care team (ICT) composed of all the people key to managing member care
• Convenes the ICT for each member at least annually and as needed
• Ensures members have a current and up-to-date individualized care plan
• Supports member during transitions of care, pre and post discharge
• Assist members with entering service requests
• Assesses quality gap reports at each visit; collaborate with care team and PCP to close these gaps
• Performs joint visits with other care team members as appropriate to address complex care needs
• Documents using a Certified Enrollee Record, in an effective manner while strictly adhering to CCA policies and procedures.
• Utilizing and depending on CCA internal resources, ensures that the plan of care is implemented in a timely manner.
• Provide outreach to members via telehealth technologies (video, chat, etc.) as appropriate for care management services.
• Active involvement in CCA projects/initiatives throughout the year
• Support needs for local/team/pod trainings or clinical seminars
• Assists CCA leadership with the development, refinement and enhancement of programs, initiatives, processes, policies, workflows, and projects.
• Mentor for new care coordinators – during and beyond their orientation period, if needed
• Support team need gaps at the discretion of Team Manager (i.e., intermittent support with team meeting or huddle facilitation, communicate updates to staff)
• Act as a role model to peers and support team members through change, set strong example of CCA’s mission and model of care.

Working Conditions:

• Work locations include residential and community sites.
• Must be willing and able to travel to member’s homes in addition to working in the local CCA office as needed.
• Reliable transportation and the ability to be active and mobile across state assigned to work

Member Facing:

☒  YES: The job has in-person contact (not telephonic/virtual) with CCA members or patients as part of the job duties.

Required Education (must have):

• High School Diploma/GED

Desired Education (nice to have):

• Associate’s or Bachelor’s degree

Desired Licensing (nice to have):

• clinical license/certification  (i.e., LPN, Medical Assistant, CHW)

MA Health Enrollment (required if licensed in Massachusetts):

• No, this is not required for the job. 

Required Experience (must have):

• 1-2 years caring for patients/members with complex medical, behavioral health, and social needs

Desired Experience (nice to have):

• 5+ years’ experience working in health care
• Experience with a Medicare Advantage population preferred.
• Experience with Substance Use Disorders

Required Knowledge, Skills & Abilities (must have):

• Experience in customer-facing role
• Strong communication skills
• Conflict management skills
• Organizational abilities

Required Language (must have):

• English

Desired Knowledge, Skills, Abilities & Language (nice to have):

• bilingual preferred