D-SNP Care Coordinator

Job Details:

Job Location:

Main Office - Santa Barbara, CA 93110, Position Type:
Full Time, Education Level: Associate's Degree, Salary Range: $26.30 - $36.82 Hourly, Travel Percentage:
None, Job Category:
Medical Management, Central Coast Hourly Range: $26.30 - $36.82 per hour

While candidates from anywhere in California are welcome to apply, there is a strong preference for those who reside on the Central Coast (Ventura, Santa Barbara, San Luis Obispo, Monterey and Santa Cruz Counties). This role may offer opportunities for remote work; however, familiarity with and proximity to our local customers is valued.

The D-SNP Care Coordinator is a non-licensed, non-clinical team member who plays a key role in supporting the delivery of Care Management services to eligible Dual Eligible Special Needs Plan (D-SNP) members. This position is responsible for member outreach, engagement, care coordination support, and ongoing follow-up activities for assigned members, including non-responders, members who decline care management services, and members requiring continued outreach and engagement.

The Care Coordinator supports continuity of care by addressing non-clinical barriers, facilitating referrals and community resource connections, coordinating logistics, and collaborating closely with RN Care Managers and Social Workers. This role serves as an important link between members, providers, and the interdisciplinary care team to promote member engagement and access to needed services.

• Conducts telephonic outreach to identify eligible members and obtains consent for enrollment into Care Management programs.
• Supports the completion of Health Risk Assessments (HRAs) by phone and manages both inbound and outbound call queues to facilitate member engagement.

• Assists RN Care Managers and Social Workers by scheduling medical, behavioral health, and LTSS appointments.
• Arranges transportation, prepares and sends member materials, and facilitates warm handoffs to providers and community-based resources.

• Tracks referrals and post-discharge follow-ups to ensure continuity of care.
• Maintains accurate logs and timely documentation in the care management system to meet regulatory and internal turnaround time standards.

• Coordinates Interdisciplinary Care Team (ICT) meetings, including scheduling, preparing agendas, and taking brief notes.
• Identifies and helps resolve non-clinical barriers within scope and escalates clinical or complex psychosocial concerns to licensed Care Management staff per established protocols.

• Conduct telephonic outreach for D-SNP Care Management (CM) program enrollment/engagement; schedule appointments, coordinate referrals, and assist with day-to-day care coordination between teams.
• Manage an assigned population of members requiring ongoing outreach, engagement, and follow-up activities, including non-responders, members who decline enrollment, and members requiring additional outreach attempts.
• Call members to check their well-being and, when appropriate, reach authorized representatives/family for coordination.
• Provide follow-up calls to support adherence to provider recommendations (e.g., medications, imaging, labs, specialist visits).
• Assist members with completing health surveys (e.g., plan surveys, HRA outreach as allowed by protocol).
• Follow up with members receiving care management/coordination services to maintain engagement.
• Mail educational materials and other pertinent information; generate, mail, and process post-program satisfaction surveys and conduct brief follow-up calls as needed.
• Advocate for members while respecting individual values and preferences.

• Respond promptly to inbound calls, place outbound calls to members, providers, and internal staff for status updates and coordination.
• Work closely with CM RNs, Social Workers, Population Health, Pharmacy, PCPs, and other team members to address member needs and close loops.
• Collaborate with internal and external care teams to coordinate care across settings throughout the healthcare continuum.
• Connect members to community resources to address social needs (SDOH) and other assistance as appropriate.
• Assist with tasks from the member-centered care plan and monitor adherence in…