Care Coach; Long-Term Services & Support

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Humana Healthy Horizons in Virginia is looking for Care Coaches who will assess and evaluate members' needs and requirements to achieve and/or maintain optimal wellness state by guiding members/families toward and facilitating interaction with resources appropriate for the care and wellbeing of members. Work assignments are often straightforward and of moderate complexity.

This role involves meeting members in the field at their home, Nursing Facility (NF) or location of the member's choice, spending quality time assessing their goals, needs and barriers and then connecting our members with quality services to promote their ultimate well‑being and drive person‑centered health outcomes.

• Provides specialized support for members receiving Long Term Services and Support (LTSS), with a focus on addressing health‑related social needs (HRSNs), providing psychosocial support, and ensuring LTSS meets the member's service needs.

• May support members residing in NFs by building relationships with facility staff, advocating for member care (including access to needed behavioral health services), and assessing the member's desire and ability to return to the community.

• Contacts members telephonically and face‑to‑face to establish goals and priorities, evaluate resources, develop plans of care, and identify LTSS providers and community partnerships to provide a combination of services and supports that best meet the needs and goals of member and caregiver through person‑centered thinking approaches.

• Develops and modifies Individual Service Plan and involves applicable members of the care team in care planning (informal caregiver coach, PCP, etc.).

• Supports members through navigation of their LTSS and related environmental and social needs.

• Utilizes available information pertaining to member to prevent the need for administration of duplicative assessments.

• Focuses on supporting members and/or caregivers utilizing an interdisciplinary approach in accessing long‑term services and support, social, housing, educational and other services, regardless of funding sources to meet their needs.

• Makes recommendations for appropriate Home and Community‑Based Services to enable member's independence in the community.

• Facilitates interactions with other payer sources, providers, and interdisciplinary care teams.

• Educates members in maintaining Medicaid eligibility.

• Assists with entry of annual

• Must reside in the Tidewater region of Virginia or surrounding counties (Hampton, New Port News, Williamsburg or York)

• Bachelor's degree in health or human services field or an active LPN license in the Commonwealth of Virginia without disciplinary action.

• Two (2) years of prior experience in health care and/or case management.

• One (1) year of experience working directly with individuals who meet the Cardinal Care Priority Population criteria (adults, pediatrics populations at risk for chronic medical conditions & high social needs).

• Intermediate to advanced computer skills and experience with Microsoft Word, Excel, and Outlook.

• Ability to use a variety of electronic information applications/software programs including electronic medical records.

• Exceptional oral and written communication and interpersonal skills with the ability to build rapport with internal and external customers and stakeholders.

• Proven ability of critical thinking, organization and problem‑solving skills.

• This role is considered patient‑facing and is part of Humana's Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB.

• Ability to travel to region‑based facilities and homes for face‑to‑face assessments and interactions with members and/or families.

• This role is part of Humana's driver safety program and therefore requires an individual to have a valid state driver's license and be expected to maintain personal vehicle liability insurance. Individual must carry vehicle insurance in accordance with their residing state minimum required limits or higher.

• Nursing home diversion or long‑term care case management…