Required Skills & Experience
Must have a current, unrestricted clinical license in Ohio as one of the following:
Registered Nurse (RN) ASN Social Worker Masters Clinical Counselor Masters
Experience
Must have experience in a healthcare-related profession, such as:
Nursing Social Work Counseling Case Management Care Coordination Discharge Planning Home Health Community Health Management
Additional Requirements
Candidates must also have:
Valid driver's license Reliable vehicle Verifiable auto insurance Acceptable driver's license record
Nice to Have Skills & Experience
Experience working with dual-eligible Medicare/Medicaid populations Experience with Medicaid and/or Medicare managed care Strong understanding of Medicare and Medicaid programs Knowledge of community resources available to high-risk or complex populations Experience developing and managing individualized care plans Experience collaborating with interdisciplinary healthcare teams Experience conducting assessments in members' homes or community settings Case Management Certification, highly preferred
Job Description
The Community Based Care Coordinator is responsible for coordinating care for individuals who are eligible for both Medicare and Medicaid. This role works directly with members living in longer term care facilities to assess medical, behavioral, and social needs, develop individualized care plans, connect members with resources, and coordinate care across providers and community organizations.
Main Responsibilities
Conduct comprehensive member assessments to identify medical, behavioral health, functional, and social needs. Develop, implement, and regularly update individualized care plans. Meet with members in their homes, healthcare settings, offices, and other community locations. Serve as a liaison between members, healthcare providers, community organizations, and other service agencies. Lead and collaborate with interdisciplinary care teams (ICTs) to coordinate member care. Coordinate transitions of care and follow up after hospitalizations or significant health events to help prevent readmissions.
Connect members with community resources, including:
Housing Transportation Food assistance Social services Other community-based programs
Educate members and families on:
Medicare and Medicaid benefits Chronic condition management Medication adherence Preventive care Available healthcare and community services Monitor member progress, health status, and adherence to the care plan. Collaborate with physicians, specialists, behavioral health providers, state agencies, and community-based organizations. Advocate for members and encourage active participation in healthcare decisions. Maintain accurate documentation of member interactions, care plans, interventions, and outcomes. Identify and address barriers to care. Report suspected abuse, neglect, or exploitation as a mandated reporter when required. Maintain compliance with applicable NCQA and CMSA standards