Coordinates, monitors and ensures that appropriate and timely primary, acute and long-term care services are provided to members across the continuum of care. Assists in coordinating services with federal and state programs, and other community services to the member. Promotes effective healthcare utilization, monitors health care resources and assumes a leadership role within the Interdisciplinary Care Team (ICT) to achieve optimal clinical and resource outcomes. Works with the Manager of Service Coordination to assess, plan, implement, coordinate, monitor, and evaluate services and outcomes to maximize the health of the Member. Receives and reviews authorizations for services from providers and members via phone, fax or written request. Office based associates may assist field based Service Coordinators with aspects of their case load and administrative duties when needed.
REPORTS TO: MANAGER, SERVICE COORDINATION
DEPARTMENT: HAWAII- CASE MANAGEMENT
POSITION LOCATION: KAPOLEI, HI 96707
- Position may be office based or field based depending on needs of the membership and/or management recommendation.
- Conducts face-to-face Health and Functional Assessments (HFA) for all members on an annual or more frequent basis (as applicable).
- Develops a Care Plan for each member, in conjunction with the PCP and member, based upon the HFA.
- Coordinates a team of decision makers including the PCP, other providers as appropriate, the member, and others as determined by the member including family members, caregivers, and significant others to become part of a member's Interdisciplinary Care Team (ICT).
- Interacts with member, family, physician(s), and other providers utilizing clinical knowledge and expertise to determine medical history and current status and to assess the options for care including use of benefits and community resources to update the Care Plan.
- Coordinates community resources with emphasis on the development of natural support system and coordinates benefits, regulations, laws and public entitlement programs.
- Provides counseling on options regarding institutional placement and HCBS alternatives.
- Coordinates services with other providers such as Medicare, DOH Programs, Medicare Advantage Plans, specialty providers, Zero-to-Three, Healthy Start, mental health, and Developmentally Disabled/Mentally Retarded (DD/MR) providers at DOH.
- Maintains HIPAA standards and confidentiality of protected health information; and reports critical incidents and information regarding quality of care issues.
- Utilizes compiled data received from member electronic record to assure that the services being provided meet the member's needs.
- Facilitates member and provider authorization and access to services.
- Seeks to resolve any concerns about care delivery or providers.
- Monitors member self-direction delivery process
- Monitors progress with Early and Periodic Screening, Diagnosis and Treatment (EPSDT) requirements.
- Refers members with suspected severe emotional, behavioral and/or mental illness for evaluation.
- Manages a caseload in accordance with state caseload ratio requirements.
- Acts as liaison and member advocate between the member/family, physician and facilities/agencies.
- Maintains accurate records of service coordination activities in the system using clinical guidelines.
- Ensures compliance with all state and federal regulations and guidelines.
- Performs other duties as assigned.
- Collaborates with other licensed Service Coordinators on cases that require more intense clinical assessment.
- Performs complex administrative tasks closely guided by policy and past clinical practice.
- Works with organization RN's to complete 1147 level of care assessments.
- Communicates effectively in person and by phone.
- Makes decisions within the scope of the job, consistent with plan/department policy and procedure.
- Assists in evaluating process improvements.
- Works independently, handles multiple assignments and prioritizes workload.
- Seeks help in managing workload, when appropriate.
- Travels to member's location of residence as needed and uses a laptop computer to complete the assessment, initial care plan and documentation.
- Demonstrates teamwork and negotiation skills.
- Uses discretion and independent judgment when applying criteria in determining case management and service needs, and other matters of clinical significance.
- Associate's Degree in a related field is required
- Bachelor's Degree in Psychology/Social Work or other relevant discipline is preferred
- Required 2 years of experience in long-term care or other relevant health care experience is required
- 3-6 years of experience in long-term care or other relevant health care experience is preferred
- Managed care experience is preferred
- Experience in working with special populations, such as HIV/AIDS, developmental disabilities, medically fragile children, geriatrics, persons with neurotrauma, and younger adults with physical disabilities is preferred
- Demonstrated interpersonal/verbal communication skills
- Ability to create, review and interpret treatment plans
- Ability to effectively present information and respond to questions from families, members, and providers
- Ability to represent the company with external constituents
- Demonstrated ability to deal with confidential information
- Demonstrated customer service skills
- Knowledge of healthcare delivery
- Demonstrated written communication skills
- Ability to implement process improvements
- Ability to work as part of a team
- Ability to work independently
- Demonstrated problem solving skills
- Microsoft Word is required
- Microsoft Excel is required
- Microsoft Outlook is required
- Healthcare Management Systems (Generic) is required
- Preferred Korean is preferred
- Preferred Mandarin is preferred
- Ilocano is preferred
- Tagalog is preferred *LI-RG1