Care Coach (Transition/Custodial Prevention)

Humana • Davenport, IA

2d • Remote

About The Position

The Care Coach 2 (Transition/Custodial Prevention Specialist) assesses and evaluates member needs and requirements to achieve and/or maintain optimal wellness state by guiding members/families toward and facilitating interaction with resources appropriate for the care and wellbeing of members. The Care Coach 2 work assignments are often straightforward and of moderate complexity. The Care Coach 2 (Transition/Custodial Prevention Specialist) will meet members in the field at home, Nursing Facility (NF) or location of the member's choice, spending quality time assessing their goals, needs and barriers and then connecting members with quality services to promote their ultimate well-being and drive person-centered health outcomes. Responsibilities include: Provides specialized support for members receiving Long Term Services and Support (LTSS), with a focus on addressing health-related social needs (HRSNs), providing psychosocial support, and ensuring LTSS meets the member's service needs. May support members residing in NFs by building relationships with facility staff, advocating for member care (including access to needed behavioral health services), and assessing the member's desire and ability to return to the community. Contacts members telephonically and face-to-face to establish goals and priorities, evaluate resources, develop plans of care, and identify LTSS providers and community partnerships to provide a combination of services and supports that best addresses the needs and goals of members and caregivers through person centered thinking approaches. Focuses on supporting members and/or caregivers utilizing an interdisciplinary approach in accessing long term services and support, social, housing, educational and other services, regardless of funding sources to meet their needs. Develops and modifies Individual Service Plans and involve applicable members of the care team in care planning (Informal caregiver coach, PCP, etc.). Supports members through navigation of their LTSS and related environmental and social needs. Utilize available information pertaining to members to prevent the need for administration of duplicative assessments. Make recommendations for appropriate Home and Community-Based Services (HCBS) to enable member's independence in the community. Facilitates interactions with other payer sources, providers, and interdisciplinary care teams. Educates members in maintaining Medicaid eligibility. Assist with entry of annual Level of Care assessment into state portal.

Requirements

• Applicants must reside in Cook County, IL, within one of the following ZIP codes, or within a 10-mile radius of these Zip Codes: 60068, 60131, 60171, 60176, 60613, 60614, 60618, 60625, 60626, 60630, 60631, 60633, 60634, 60639, 60640, 60641, 60645, 60646, 60647, 60657, 60659, 60660, 60706, 60707, 60712, 60104, 60130, 60141, 60153, 60155, 60160, 60163, 60164, 60165, 60301, 60302, 60303, 60304, 60402, 60424, 60475, 60513, 60534, 60546, 60601, 60605, 60606, 60607, 60608, 60609, 60610, 60611, 60612, 60615, 60616, 60622, 60623, 60624, 60632, 60642, 60644, 60651, 60653, 60654, 60661, 60680, 60690, 60699, 60804, 60305.
• Bachelor's degree in social sciences, social work, human services, or a related field.
• Two (2) years of prior experience working with Medicare and Medicaid recipients, long-term care services, Home and Community-Based Services (HCBS), and/or managed care organizations.
• One (1) or more years of professional experience working with members in custodial and transitional care.
• Ability to use a variety of electronic information applications/software programs including electronic medical records.
• This role is considered patient facing and is part of Humana's Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB.
• Ability to travel in the region to meet face to face with members and/or their families, community partners and care teams.
• This role is part of Humana's driver safety program and therefore requires an individual to have a valid state driver's license and are expected to maintain personal vehicle liability insurance. Individuals must carry vehicle insurance in accordance with their residing state minimum required limits, or $25,000 bodily injury per person/$25,000 bodily injury per event /$10,000 for property damage or whichever is higher.

Nice To Haves

• An active, unrestricted Licensed Professional Counselor (LPC), Licensed Social Worker (LSW) or Registered Nurse (RN) in Illinois.
• Nursing home diversion or long-term care case management experience.
• Experience working with a Waiver Program.
• Experience with Medicare & Medicaid recipients.
• Experience working with complex health population.
• Experience with health promotion, coaching and wellness.
• Knowledge of community health and social service agencies and additional community resources.
• Bilingual or Multilingual: English/Spanish, Arabic, Vietnamese, Amharic, Urdu or other - Must be able to speak, read and write in both languages without limitations and assistance. See "Additional Information" section for language assessment information.

Responsibilities

• Provides specialized support for members receiving Long Term Services and Support (LTSS), with a focus on addressing health-related social needs (HRSNs), providing psychosocial support, and ensuring LTSS meets the member's service needs.
• May support members residing in NFs by building relationships with facility staff, advocating for member care (including access to needed behavioral health services), and assessing the member's desire and ability to return to the community.
• Contacts members telephonically and face-to-face to establish goals and priorities, evaluate resources, develop plans of care, and identify LTSS providers and community partnerships to provide a combination of services and supports that best addresses the needs and goals of members and caregivers through person centered thinking approaches.
• Focuses on supporting members and/or caregivers utilizing an interdisciplinary approach in accessing long term services and support, social, housing, educational and other services, regardless of funding sources to meet their needs.
• Develops and modifies Individual Service Plans and involve applicable members of the care team in care planning (Informal caregiver coach, PCP, etc.).
• Supports members through navigation of their LTSS and related environmental and social needs.
• Utilize available information pertaining to members to prevent the need for administration of duplicative assessments.
• Make recommendations for appropriate Home and Community-Based Services (HCBS) to enable member's independence in the community.
• Facilitates interactions with other payer sources, providers, and interdisciplinary care teams.
• Educates members in maintaining Medicaid eligibility.
• Assist with entry of annual Level of Care assessment into state portal.

Benefits

• medical, dental and vision benefits
• 401(k) retirement savings plan
• time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave)
• short-term and long-term disability
• life insurance
• many other opportunities

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level