Field Care Coordinator

About This Role

The Field Care Coordinator is responsible for coordinating person-centered care for individuals receiving long-term services and support, aiming to simplify the health care experience and remove barriers to quality care.

Responsibilities

• Develop and implement care plan interventions throughout the continuum of care as a single point of contact
• Communicate health-related information to ensure quality coordinated care and services are provided expeditiously to all members
• Advocate for persons and families to ensure patient's needs and choices are fully represented and supported by the health care team
• Assess, plan, and implement care strategies individualized by the individual and directed toward the most appropriate, least restrictive level of care
• Identify problems/barriers to care and provide appropriate care management interventions
• Identify and initiate referrals for social service programs, including financial, psychosocial, community and state supportive services
• Provide resource support to members for local services (e.g., CSHCS, employment, housing, independent living, foster care)
• Manage the person-centered service/support plan throughout the continuum of care
• Conduct home visits in coordination with the person and care team
• Conduct in-person visits, which may include nursing homes, assisted living, hospital or home
• Gather, document, and maintain all member information and care management activities to ensure compliance with current state and federal guidelines

Requirements

• Current, unrestricted independent licensure as a Registered Nurse (RN) in state of Michigan OR Master's degree and current, unrestricted independent licensure as a Social Worker (e.g., LMSW, LCSW, LLMSW) OR Bachelor's degree and current, unrestricted independent licensure as a Social Worker (e.g. LLBSW, LBSW)
• 2+ years of experience working within the community health setting in a healthcare role
• 1+ years of experience with local behavioral health providers and community support organizations addressing Social Determinants of Health (SDoH)
• 1+ years of experience working with persons with long-term care needs and/or home and community-based services
• 1+ years of experience working in electronic documentation systems and with MS Office (Outlook, Excel, Word)
• Access to a designated quiet workspace in your home with the ability to secure Protected Health Information (PHI)
• Ability to travel within assigned territory to meet with members and providers up to 75% of the time
• Ability to travel to Southfield, MI office for quarterly team meetings
• Reside within the state of Michigan
• Access to reliable transportation and valid US driver's license

Qualifications

• Master's degree or Bachelor's degree as a Social Worker, or current, unrestricted independent licensure as a Registered Nurse (RN) in state of Michigan
• 2+ years of experience working within the community health setting in a healthcare role; 1+ years of experience with local behavioral health providers and community support organizations addressing SDoH; 1+ years of experience working with persons with long-term care needs and/or home and community-based services; 1+ years of experience working in electronic documentation systems and with MS Office

Nice to Have

• RN or LMSW, LLMSW, LCSW
• 1+ years of medical case management experience
• Demonstrated experience/additional training or certifications in Motivational Interviewing, Stages of Change, Trauma-Informed Care, Person-Centered Care
• Experience in serving individuals with co-occurring disorders (both mental health and substance use disorders)
• Experience with MI Health Link (MMP)
• Experience working in Managed Care
• Working knowledge of NCQA documentation standards

Skills

* Required skills

Benefits