External Care Coordination Specialist

This position is ensures that members of Amida Care are receiving the care necessary to meet their needs and make sure that this care is coordinated amongst providers. Acts as a liaison between providers and staff at assigned facility/facilities and the Integrated Care Teams (ICTs) at Amida Care. Assists with scheduling appointments, coordinating and following up on referrals, facilitating clinical documentation to and from the Plan, coordinating discharge planning, providing medication adherence support, and delivering targeted health education. Primarily a field-based position with a four-day assignment at a Health Center or Hospital in the community and one-day spent at Amida Care offices in weekly ICT meetings and receiving supervision.

• Maintain members in medical care through coordination of care with primary care providers, behavioral health providers, specialists, and other ancillary service providers. Collaborate with Amida Care’s Integrated Care Teams (ICTs) to ensure member needs are addressed in a timely manner.
• Coordinate appropriate referrals, schedule appointments, and ensure appointments are kept through the provision of regular follow up to both members and providers.
• Act as bridge between Amida Care and Providers, hospitals, and agencies within the community to facilitate seamless transfer of information about the status of members.
• Facilitate obtaining essential documentation and information, such as HIV verification documentation, laboratory test results, appointment adherence, case management assessments, prior authorizations, medical records from the assigned site(s).
• Conduct outreach to members currently hospitalized and coordinate with members of their treatment team to facilitate pre-discharge engagement. Coordinate discharge plans for members currently receiving inpatient medical, mental health and/or substance use disorder care.
• Assist members in need of intensive aftercare outreach and provide education and support through follow-up and reminder calls, as well as, coordinating escorts/transportation to appointments as needed.
• Ensure members receive seven (7) and thirty (30) day post hospitalization follow-up care. Contact providers to confirm members kept post-hospitalization appointments. Provide alternate aftercare referrals for members not engaged in care after discharge.
• Develop and maintain an intimate connection with Health Homes staff at assigned site(s) and collaborate with them to facilitate a smooth transfer of information and services.

• Associate’s Degree in a health, medical or a related field or an equivalent combination of education and experience required. Bachelor of Social Work (BSW), Licensed Practical Nurse (LPN) or related degree/license preferred.
• Two (2) years’ experience working with individuals living with HIV/AIDS or other chronic conditions with complex needs is required. Experience working within a Community Based Organization, private physician’s practice or Health Center is strongly preferred. Experience with medical charting is preferred.
• Ensure member confidentiality and adhere to Confidentiality and Health Insurance Portability and Accountability Act (HIPPA) policies and regulations policies and regulations.
• Strong knowledge of Microsoft Office (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.

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