Community Based Care Coordinator - Quality Focus

Job Summary

The Community Based Care Coordinator, Duals Integrated Care is responsible for managing and coordinating care for dual-eligible beneficiaries, those who qualify for both Medicare and Medicaid. This position focuses on integrating health services and community resources to improve health outcomes and enhance the quality of life for individuals with complex health needs. More specifically, this Quality-focused role carries an enhanced responsibility for supporting HEDIS performance, proactively identifying and closing gaps in care, and driving key quality outcomes across the dual‑eligible population.

• Engage with the member in a variety of community‑based settings to establish an effective, care coordination relationship, while considering the cultural and linguistic needs of each member.
• Function as a liaison between healthcare providers, community resources, and dual‑eligible beneficiaries to ensure seamless communication and care transitions.
• Conduct comprehensive assessments to identify the physical, mental, and socials needs of dual‑eligible individuals.
• Develop and implement individualized care plans based on unique needs of each member, considering their medical, social, and behavioral health requirements.
• Lead and collaborate with interdisciplinary care team (ICT) to create holistic care plans that address medical and non‑medical needs.
• Assist members in accessing community resources, including housing, transportation, food assistance, and social services.
• Educate members about their benefits and available services under both Medicare and Medicaid.
• Provide education to members and their families about managing chronic conditions, medication adherence, and preventive care.
• Promote health lifestyle choices and self‑management strategies.
• Regularly monitor member’s health status and care plan adherence, adjusting, as necessary.
• Follow up with members after hospitalizations or significant health events to ensure continuity of care and prevent readmissions.
• Work closely with primary care physicians, specialists, and other healthcare providers to coordinate care and share relevant information.
• Coordinate with community‑based organizations, other stakeholders/entities, state agencies, and other service providers to ensure coordination and avoid duplication of services.
• Participate in care team meetings to discuss member progress and address barriers to care.
• Maintain accurate and up‑to‑date records of members interactions, care plans, and outcomes.
• Collect and analyze data to evaluate the effectiveness of care coordination efforts and identify areas of improvement.
• Advocate for the needs and preferences of dual‑eligible beneficiaries within the healthcare system.
• Empower members to take an active role in their healthcare decisions.
• Evaluate member satisfaction through open communication and monitoring of concerns or issues.
• Regular travel to conduct member, provider and community‑based visits as needed and per the regulatory requirements of the program.
• Report abuse, neglect, or exploitation of older adults as a mandated reporter as required by State law.
• On‑call responsibilities as assigned.
• Adherence to NCQA and CMSA standards.
• Performs any other job related duties as requested.

• Nursing degree from an accredited nursing program required or
• Bachelor's degree in a health care field required
• Equivalent years of relevant work experience may be accepted in lieu of required education
• Previous experience in nursing, social work, counseling or health care profession (i.e. discharge planning, case management, care coordination, and/or home/community health management) experience required
• Prior experience in care coordination, case management, or working with dual‑eligible populations preferred
• Medicaid and/or Medicare managed care experience preferred

• Intermediate proficiency level with Microsoft Office, including Outlook, Word and Excel
• Understanding of Medicare and Medicaid programs, as well community resources and services available to dual‑eligible beneficiaries
• Strong interpersonal and communication skills to effectively engage with…