Field Care Coordinator - Allegheny or Rockbridge Counties in VA Market - Remote

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This is a field-based position based in Alleghany and Rockbridge County VA Markets.

The Field Care Coordinator is responsible for facilitating, promoting, and advocating for the enrollees' ongoing self-sufficiency and independence. This position is responsible for assessment and planning for an identified group of patients. Additionally, the care coordinator is responsible for assessing the availability of natural supports such as the enrollee's representative or family members to ensure the ongoing mental and physical health of those natural supports.

The Field Care Coordinator collaborates with the Interdisciplinary Team to coordinate the delivery of comprehensive, efficient, cost-effective patient care. The Field Care Coordinator will be traveling into enrollees' homes, nursing facilities, Adult Day Health, and Adult Living Facilities (ALF) to conduct in-depth assessments and develop the plan of care. The Field Care Coordinator actively assists enrollees with care transitions in collaboration with the Interdisciplinary Team and the acute or skilled facility staff, and the enrollees and / or the enrollees' representatives.

Field Care Coordinators act as liaison between the Health Plan, the Commonwealth, enrollees, and their families. Field Care Coordinators follow established professional standards of care, Commonwealth guidelines and policy and procedures.

If you are located in commutable distance of Alleghany or Rockbridge Counties in VA, you will have the flexibility to work remotely
* as you take on some tough challenges. For all hires in the Minneapolis or Washington, D.C. area, you will be required to work in the office a minimum of four days per week.

• Engage members face-to-face and/or telephonically to complete a comprehensive needs assessment, including assessment of medical, behavioral, functional, cultural, and socioeconomic needs
• Develop and implement person centered care plans to address needs including management of chronic health conditions, health promotion and wellness, social determinants of health, medication management and member safety in alignment with evidence-based guidelines
• Partner and collaborate with internal care team, providers, and community resources/partners to implement care plan
• Provide education and coaching to support member self-management of care needs and lifestyle changes to promote health
• Support proactive discharge planning and manage/coordinate Care Transition following ER visit, inpatient or Skilled Nursing Facility (SNF) admission
• Advocate for members and families as needed to ensure the member's needs and choices are fully represented and supported by the health care team

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

• Current and unrestricted Licensed Practical Nurse in the state of Virginia OR Social Work or Human Services (or related field) with a 4-year degree
• 3+ years of care coordination or behavioral health experience and/or work in a healthcare environment
• 1+ years of experience with MS Office, including Word, Excel, and Outlook
• Experience working with members who have medical needs, the elderly, individuals with physical disabilities and / or those who may have communication barriers
• Driver's license and reliable transportation and the ability to travel within assigned territory to meet with members and providers

• CCM certification
• Experience working with Medicaid / Medicare population
• Experience working in team-based care
• Long term care / geriatric experience
• Background in Managed Care