Full Time - Regular
Roseburg, OR, US
The Care Coordinator (CC) organizes care management services and establishes care plans for Umpqua Health Alliance (UHA), Oregon Health Plan (OHP) enrollees, and collaborates with the care of specific Medicare members. The CC will adhere to regulatory and compliance requirements, department productivity/quality metrics and provide exceptional customer service to all internal and external customers.
ESSENTIAL JOB RESPONSIBILITIES
• Review and remain current of local and OHP medical care and services per established rules and guidelines.
• Maintain updated knowledge of the Oregon Administrative Rules (OAR) governing OHP.
• Remain current on Medicare guidelines, the appeals and grievance process, and the members' rights and responsibilities as stated by the Division of Medical Assistance Program (DMPA), Oregon Health Authority (OHA), and Centers for Medicare and Medicaid Services (CMS.)
• Demonstrate an on-going understanding and current knowledge of benefits for Medicare and Medicaid populations.
• Assist members with special health care needs, care coordination and other related issues.
• Consider predictive modeling, screening and other data, where appropriate, in deciding whether a member would benefit from case management services. Utilize screenings to identify member's unmet needs. Coordinate with members as needed for community services and primary care, connecting the members with appropriate level of care.
• Conduct assessments of the member's health, physical, functional, behavioral, psychological, and social needs, including health literacy status and deficits, self-management abilities and engagement in taking care of own health, availability of psychosocial support systems including family caregivers, and socioeconomic background. The assessment leads to the development and implementation of a member- specific case management plan of care in collaboration with the member and family or family caregiver, and other essential health care professionals.
• Planning the care interventions and needed resources with the member, family or family caregiver, the PCP, or other health care professionals, and the community-based agents, to maximize the member's health care responses, quality, safety, cost-effective outcomes, and optimal care experience.
• Facilitating communication and coordination among members of the inter-professional health care team, and involving the member in the decision-making process in order to minimize fragmentation in the services provided and prevent the risk for unsafe care and sub-optimal outcomes. Collaborating interdepartmentally with Behavioral Health, Pharmacy and Member services as appropriate.
• Communicating on an ongoing basis with the member, member's family or family caregiver, other involved health care professionals and support service providers, via phone or in-person; assuring that all are well-informed and current on the case management plan of care and services. Maintain regular contact with member, based on mutually agreed timetable for regular follow-up and care plan updates.
• Advocate and navigate within the health care system and community to assist the member with care.
• Document coordination and member need in appropriate systems.
• Evaluate the value and effectiveness of case management plans of care, resource allocation, and service provision while applying outcomes measures reflective of organizational policies and expectations, accreditation standards, and regulatory requirements.
• Engage in performance improvement activities with the goal of improving member's access to timely care and services, and enhancing the achievement of target goals and desired outcomes.
• Comply with organization's internal policies and procedures, Code of Conduct, Compliance Plan, along with applicable Federal, State, and local regulations.
• Complexity of duties may vary based on the level of experience, education and qualifications of coordinator.
• Other duties as assigned.
A current medical licensure is required, type of licensure is based on level of Care Coordinator;
• Level 1: Any valid medical license (examples include; MA, LPN, EMT, CNA, RT.) Some medical background preferred.
• Level 2: MA, LPN, RN, EMT with a minimum of 2 years in care coordination or similar field.
• Level 3: RN, BSN, LCSW or a minimum of 5 years of experience in care coordination.
• Level 4: RN, BSN, LCSW, FNP, or a minimum of 10 years of experience in care coordination.
• Previous case management or care coordination experience preferred.
• Previous experience in a managed care setting preferred.
• Experience following established medical guidelines required.
• Clinical knowledge of the health or social work needs for the population served.
• Demonstrated ability to identify barriers to a successful care management path.
• Ability to interact effectively and professionally with internal and external customers.
• Proficient PC Navigational skills required; solid data entry and MS Office skills required.
• Excellent critical thinking and time management skills.
• Excellent written, verbal and interpersonal communication skills, with demonstrated ability to provide exceptional customer service to internal and external customers.
• Demonstrated transferable knowledge, skill and ability to complete job duties independently and proficiently.
• Ability to manage multiple priorities with attention to detail and follow-up.
• Valid Oregon driver's license required.
• Must have reliable means of transportation and able to travel periodically.
• The ability to occasionally work more than 40 hours in a week and to work flexible hours to include occasional weekends and holidays is required and is a condition of employment.