Field Care Coordinator – Fairfax, VA
About The Position
The Field Care Coordinator facilitates, promotes, and advocates for enrollees’ self-sufficiency and independence. The role assesses and plans for an identified group of patients, including considering the availability of natural supports such as family members or an enrollee’s representative. The coordinator collaborates with the Interdisciplinary Team to arrange comprehensive, efficient, and cost-effective care. The position is field-based with a home-based office and requires travel throughout Fairfax, Prince William, Fauquier, and Loudoun counties in Virginia and surrounding areas. The coordinator visits enrollees in homes, nursing facilities, Adult Day Health settings, and Adult Living Facilities to conduct assessments and develop plans of care. The role also supports care transitions in collaboration with the Interdisciplinary Team, facility staff, enrollees, and their representatives, and serves as a liaison among the Health Plan, the Commonwealth, enrollees, and families. Work follows professional standards of care and Commonwealth guidelines, policies, and procedures.
Requirements
- Bachelor’s degree in Social Work, Human Services, or a related field.
- At least 3 years of experience in care coordination, behavioral health, and/or a healthcare environment.
- At least 3 years of experience working with members with medical needs, elderly people, individuals with physical disabilities, and/or people who may have communication barriers.
- At least 1 year of experience with MS Office, including Word, Excel, and Outlook.
- Valid driver’s license, reliable transportation, and ability to travel within the assigned territory to meet with members and providers.
Nice To Haves
- Current and unrestricted Licensed Practical Nurse license in Virginia.
- CCM certification.
- Experience working with Medicaid or Medicare populations.
- Experience working in team-based care.
- Long-term care or geriatric experience.
- Background in managed care.
- ACM certification.
Responsibilities
- Engage members face-to-face and/or by telephone to complete comprehensive needs assessments covering medical, behavioral, functional, cultural, and socioeconomic needs.
- Develop and implement person-centered care plans addressing chronic health conditions, health promotion and wellness, social determinants of health, medication management, and member safety in accordance with evidence-based guidelines.
- Partner and collaborate with the internal care team, providers, and community resources or partners to implement care plans.
- Provide education and coaching to support member self-management of care needs and lifestyle changes that promote health.
- Support proactive discharge planning and manage or coordinate care transitions following an emergency room visit or an inpatient or Skilled Nursing Facility admission.
- Advocate for members and families to ensure members’ needs and choices are represented and supported by the health care team.
- Assess the availability of natural supports to help ensure enrollees’ ongoing mental and physical health.
- Travel to enrollees’ homes and care facilities to conduct in-depth assessments and develop plans of care.
- Act as a liaison between the Health Plan, the Commonwealth, enrollees, and their families.
Benefits
- Comprehensive benefits package, subject to eligibility requirements.
- Incentive and recognition programs.
- Equity stock purchase.
- 401(k) contribution, subject to eligibility requirements.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
