Care Coordinator; Care Manager - Registered Nurse; RN), Social Worker, or Clinical Counselor

Care Coordinator (Care Manager) - Registered Nurse (RN), Social Worker, or Clinical Counselor 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. The role focuses on integrating health services and community resources to improve health outcomes and enhance the quality of life for individuals with complex health needs, including those eligible for waiver services.

• Engage with members in community‑based settings to establish effective care‑coordination relationships, considering cultural and linguistic needs.
• Act as 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 social needs of beneficiaries.
• Develop and implement individualized care plans based on unique member needs, incorporating medical, social, and behavioral health requirements.
• Lead and collaborate with interdisciplinary care team (ICT) to create holistic care plans addressing all needs.
• Assist members in accessing community resources such as housing, transportation, food assistance, and social services.
• Educate members about benefits and available services under Medicare and Medicaid.
• Provide education on managing chronic conditions, medication adherence, and preventive care.
• Promote healthy lifestyle choices and self‑management strategies.
• Regularly monitor members’ health status and care‑plan adherence, adjusting as necessary.
• Follow up after hospitalizations or significant health events to ensure continuity of care and prevent readmissions.
• Coordinate with primary care physicians, specialists, and other providers to share relevant information.
• Collaborate with community organizations, state agencies, and other stakeholders to avoid duplication of services.
• Participate in care team meetings to discuss progress and identify barriers to care.
• Maintain accurate and up‑to‑date records of interactions, care plans, and outcomes.
• Collect and analyze data to evaluate the effectiveness of care‐coordination efforts.
• 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.
• Travel regularly to conduct member, provider, and community visits as required.
• Report abuse, neglect, or exploitation of older adults as mandated by state law.
• Perform on‑call duties as assigned.
• Adhere to NCQA and CMSA standards.
• Perform any other reasonable duties as requested.

• Nursing degree from an accredited program or a bachelor’s degree in a health‑care field, or equivalent experience, is required.
• Prior experience as a nurse, social worker, counselor, or health‑care professional in discharge planning, case management, care coordination, or home/community health management is required.
• Experience in care coordination, case management, or working with dual‑eligible populations is preferred.
• Experience with Medicaid and/or Medicare managed care is preferred.

• Intermediate proficiency with Microsoft Office (Outlook, Word, Excel).
• Understanding of Medicare, Medicaid, and community resources available to dual‑eligible beneficiaries.
• Strong interpersonal and communication skills to engage members, families, and providers.
• Ability to manage multiple cases and priorities while maintaining attention to detail.
• Adherence to a professional code of ethics.
• Awareness of and sensitivity to diverse backgrounds and needs.
• Decision‑making and problem‑solving skills.

• Current unrestricted clinical license in the state of practice as a Registered Nurse, Social Worker, or Clinical Counselor is required.
• Case‑management certification is highly preferred.
• Valid driver’s license, vehicle, and verifiable insurance are required.
• Influenza vaccination required during the influenza season (October 1 – March 31); annual…