Health Coordinator, RN or SW

Health Coordinator

The Health Coordinator is responsible for conducting face-to-face assessments, developing individualized health action plans, interacting with members, providers, and physicians to coordinate primary, acute, behavioral, and long-term services and support (LTSS) for individuals having special health care needs. Job functions are performed in accordance with the requirements of the QUEST Integration contract and health plan goals and quality outcome metrics.

Primary Duties and Responsibilities:

• Conducts face-to-face or virtual (video chat) Health and Functional Assessments (HFA) for all Special Health Care Needs, Expanded Health Care Needs, Long-Term Services and Supports, Community Integration Service Needs, or Community Care Service Needs members on an annual or more frequent basis (as applicable) and a Level of Care Assessment (DHS Form 1147) for members needing long term care.
• Engages member/providers to participate in the assessment process and collaboratively develop a person-centered Health Action Plan for each member, based upon the HFA, DHS-1147, or other assessments.
• Ensures the Health Action Plan is a person-centered individualized plan that is developed with the Member and/or authorized representative, is based on an assessment and developed within no more than 30 calendar days of completion of the assessment.
• Interacts with members, family, physician(s), and other providers utilizing clinical and social knowledge and expertise to determine the member's current status and capacity and to assess the options for service delivery including use of health plan benefits and community resources to update a Member's Health Action Plan.
• Meets with members at a minimum every 90 days in-person or via video chat to monitor and document the Member's progress of goals and services in the Health Action Plan.
• Screens for social risk factors and incorporate information on the results of positive screens into clinical decision making and offer screened members interventions to mitigate the impact of social risk factors, including timely referrals with positive screens.
• Assists the members with connection to social services to help find and apply for housing necessary to support the individual in meeting their medical care needs.
• Facilitates authorization and access to services.
• Verifies authorized or coordinated services have been provided.
• Monitors and resolves any concerns about delivery of service or providers and ensures that the services being provided meet the members' needs.
• Surveys members to ensure member satisfaction with providers and services.
• Provides individualized education on preventative health care measures.
• Provides information on HCBS alternatives to nursing facility placement and the choice of Self-Direction of HCBS.
• Monitors and performs health coordination activities for members in Self-Direction program.
• Monitors the Electronic Visit Verification portal for completed visits including completion of time sheets when needed.
• Ensures members complete annual primary care visits, routine and preventative screenings, and other care gaps related to quality initiatives.
• Assists members in transitioning between hospital, nursing facility, other congregate settings and other community-based locations ensuring a seamless and continuous coordination of care across a continuum of care.
• Refers to and works with Hawaii CARES to ensure Members receive, SUD, mental health, and co-occurring treatment and recovery support services, as well as crisis intervention and support services in a timely manner.
• Connect members with Social Determinates of Health (SDoH) needs with any Community Resources in their neighborhood or area or utilizing the Unite Us tool.
• Coordinates care with members receiving services through AMHD, CAMHD and DDD programs.
• Meets operational and compliance with due dates for assessments, care plans, and all regulatory required activities.
• Perform tasks that align with and support departmental and organizational objectives.
• Maintains accurate written documentation and records of health coordination activities in case management systems according to appropriate service coordination and/or clinical guidelines.
• Ensures compliance with all state and federal regulations, including HIPAA standards of confidentiality of protected health information, reporting critical incidents and reporting of quality-of-care issues.
• All other duties assigned.
• Adhere to regulatory compliance and quality guidelines as well as Aloha Care policies and procedures.
• Responsible for maintaining Aloha Care's confidential information in accordance with Aloha Care policies, and state and federal laws, rules and regulations regarding confidentiality. Employees have access to Aloha Care data based on the data classification assigned to this job title.

Requirements:

• Associate's, Bachelor's, or Master's degree in Health Care Administration, Nursing, Social Work, Public Health, or related field or equivalent combination of education and…