Care Coordinator

**Job Details** Works with minimal supervision to ensure that comprehensive, patient\-centered quality of care, cost effective patient care is offered for members in need of care coordination. All care coordination follows NCQA standards for Complex Case Management and is based on evidence\-based guidelines. Review medication profiles member history verify appropriate testing and facilitate office visits with primary care and specialist physicians for members targeted for care coordination services. Coordinate with hospital and provider office case managers, as applicable, to ensure continuity of care and outpatient services when medically appropriate. Coordinate with behavioral health to ensure continuity of care and develop care plans. Perform outreach, education, and follow\-up to members based on criteria determined by Operational Guidelines. Utilize community resources to assist in coordinating care to maximize positive health outcomes. Collaborate with other members of Health Partner Plans to perform targeted outreach directed at improving outcomes through screenings and preventive health. Work with practice sites to remove barriers to care, improve member self\-management and improve member outcomes. **Job Description** * Able to work in a constant state of alertness and safe manner. * Assumes primary responsibility for providing case management for identified members, including home, hospital and provider/ community site visits as appropriate. * Conduct timely telephonic outreach to members who have chronic conditions to improve health outcomes to include but not limited to: * Assist primary care provider office(s) in coordinating care of members with complex medical needs; utilizing appropriate assessments in software. * Coordinating care for members that is member focused, taking into account the members barriers to care and their personal goals. * Documentation in software that includes capturing the member’s barriers to care, priority goals, plans of care and schedule for follow up. * Applies knowledge of pathophysiology, psychosocial issues, confidentiality, ethical/legal issues, and therapeutic interventions and sources to assist the membership with problem\-solving/decision\-making that promotes health, improves level of functioning, and decreases inappropriate use of services. * Educating members concerning their specific health care needs. * Researching and coordinating care with available community resources. * Researching and coordinating care with member’s behavioral health provider. * Informing members about Jefferson Health Plans Medicaid benefits. * Educates members on their specific health care needs and care options, including palliative care, as appropriate. * Facilitates accommodations for members with language, communication, visual or mobility limitations. * Provides approved educational materials that supports goals and interventions. * Coordinate and collaborate care with external as well as internal Health Partners Plans resources to meet the individual needs of the member identified by the assessment and subsequent outreach; * Assist primary care provider offices and specialist offices in coordinating care of members; * Perform literature searches and follow up to date clinical guidelines in coordinating member care and services; * Actively seek guidance from assigned Medical Director or designee as appropriate. * Actively participate in multidisciplinary team meetings to represent care coordination program; Meetings include, but not limited to, Medical Director Rounds and BH Collaborative Meeting. * Collaborate with behavioral health MCOs and the member to develop, assist with implementation of, and follow up on interdisciplinary care plans for members with serious, persistent mental illness (SPMI). * Work collaboratively within the Health Care Management department on tasks as needed; * Refer appropriate cases to departments within Health Partners Plans to assist with quality of care and utilization management. * Keep current on existing programs within the community as well as the needs of the population. * Balances the dual roles of advocacy for the member and stewardship of fiscal resources by assisting the member to identify and utilize all available resources. * Participates in multidisciplinary and interdepartmental collaboration, reporting and special projects as assigned. * Support Jefferson Health Plans mission * Other duties as assigned that may include but not limited to performing responsibilities of other JHP care management units. **Education and Experience:** Bachelors degree required Current clinical/case management experience required Experience including medical/surgical, home care, DME, authorizations, and case management preferred Bilingual in a language spoken by membership is preferred **License and Certification Requirements:** Active LPN, LSW, or RN license in the state of PA CCM upon hire or must obtain within 2 years of hire eligible. If not eligible for certification must be supervised by a certified case manager. **Work Shift** Workday Day (United States of America) **Worker Sub Type** Regular **Employee Entity** Health Partners Plans, Inc. **Primary Location Address** 1101 Market, Philadelphia, Pennsylvania, United States of America Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest\-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st\-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University , home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200\+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health , nationally ranked as one of the top 15 not\-for\-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not\-for\-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years. Jefferson is committed to providing equal educational and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status. **Benefits** Jefferson offers a comprehensive package of benefits for full\-time and part\-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD\&D insurance, short\- and long\-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts. Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service. All colleagues, including those who work less than part\-time (including per diem colleagues, adjunct faculty, and Jeff Temps ), have access to medical (including prescription) insurance. For more benefits information,