This position serves as an integral part of the her/his assigned Integrated Care Team (ICT) and is responsible for coordination of services related to the delivery of medical benefits that ensure members’ complex medical, behavioral, pharmaceutical and psychosocial needs are met within the established benefit policies and guidelines for the treatment and evaluation of members of a specialized needs plan. The Care Coordinator must have strong critical thinking skills to provide clinical oversight to the team and to clinical case reviews.
• Participate in regularly scheduled ICT Meetings. Ensure Amida Care’s Integrated Care Model of Care is operationalized within the team structure and that members’ complex, multi-disciplinary service needs are met.
• Perform clinical oversight of case review, employing critical thinking skills and presenting cases to medical directors and other clinicians.
• Coordinate access to behavioral healthcare including review of all HCBS (Home and Community-Based Service) plans of care and complete necessary written clinical documentation for response to providers, overseeing and logging all transactions.
• Perform daily review of inpatient census to ensure members are receiving care and services in accordance with established clinical guidelines and in the most appropriate care setting. Follow up with members and providers when a need is identified that will support improved health outcomes for behavioral and physical health
• Communicate with members of the healthcare team to ensure members are receiving services and care in accordance with established clinical guidelines and the Plan’s benefit package; review clinical documentation, including laboratory values, to ensure members are receiving appropriate care and implement strategies to address unmet needs as appropriate. Ensure completion of documented care coordination within the Amida Care authorized operating systems.
• Perform daily review of inpatient Census to ensure members are receiving care and services in accordance with established clinical guidelines and in the most appropriate care setting. Follow up with members and providers when a need is identified and complete post-discharge calls.
• Provide direction and support to staff to ensure timely collection of data, ongoing provider and member outreach and documentation of outreach activities and outcomes.
• Coordinate member access to other services such as home health care, Medical Home, durable medical equipment, hospice care, pharmaceutical, vision, transportation and family planning.
• Conduct Utilization Management determinations in accordance with Article 49- Utilization Review. Review clinical documentation, claims/utilization data to ensure members are receiving appropriate care and implement strategies to address unmet needs as appropriate.
• Review and assist in the resolution of member grievances within required regulatory timeframes.
• Conduct member/provider education, including but not limited to prevention, health promotion, providing appropriate level of care/services specific to enrollee’s health status, Plan benefits, Utilization Review processes, etc.
• Ensure collection and review of required documentation such as HIV verification and ICT weekly reports.
• NYS Licensed practical Nurse with three (3) years managed care experience
• Two (2) years’ experience in setting treating physical and behavioral health
• Two (2) years’ HIV/AIDS or serious chronic illness care experience.
• Healthcare and staff leadership experience preferred.
• Demonstrated knowledge of Article 49- Utilization Review process.
• Strong knowledge of Microsoft Office (Access, Word and Excel).
• Demonstrate understanding and sensitivity to multi-cultural values, beliefs, and attitudes of both internal and external contacts.
• Demonstrate appropriate behaviors in accordance with the organization’s vision, mission, and values.