Review and interview potential members to verify eligibility for enrollment in the Health Homes Program (HHP)
Complete referral process when necessary
Orient and educate members and their families by meeting with them to explain the role of the Care Coordinator
Initiate a care plan and provide educational information related to treatments, procedures, medications, and continuing care requirements in coordination with healthcare providers
Work with healthcare professionals, community and social support services, and other company employees
Document evidence of care in the member’s record in a concise and timely manner using the EHR system
Routinely check in or schedule appointments with assigned members
Maintain documentation of all member encounters to complete established reporting requirements
Communicate with providers and care team regarding member progress and care needs
Explain and translate information related to the member’s care to and on behalf of the member, when necessary
Identify and follow up on all referrals made to assure continuity of care and that member/family needs have been met
Reassess care plans to ensure effectiveness in achieving desired outcomes for members and their family
Address member questions and process member requests in a timely manner
Investigate and direct member inquiries or complaints to appropriate staff members, including follow ups to ensure satisfactory resolution
Follow established policies to enroll and disenroll members
Maintain knowledge of community services and resources available to members including housing resources, financial/income assistance, transportation assistance and food assistance
Follow established protocol around patients experiencing pain, safety concerns and/or mental health concerns and creates safety plans, if necessary
Recognize signs of child and elder abuse and report appropriately to Child/Adult Protective Services
Understand and abide by all departmental and companywide policies and procedures
Comply with all safety and injury prevention policies and regulations
Perform other duties as assigned or required
Requirements
Bachelor’s degree in sociology, social work, public health, physiology, other related field, or an associate degree and minimum 1+ years of experience
Current and valid Driver’s License
Proof of auto insurance
Distraction-free home workspace with a secure internet connection
Fluent in English (written and verbal), Bilingual in Spanish
Excellent verbal and written communication skills, including the ability to convey and exchange information in a clear and concise manner
Adequate hearing and vision (with corrective devices if necessary) to conduct assessments and documentation
Ability to identify problems and use logic and related information to develop and implement solutions
Excellent organizational skills and attention to detail
Ability to work independently and carry out assignments to completion within the parameters of established policies and procedures
Ability to communicate clearly in-person, by phone, and electronically
Frequent use of computers, keyboard, and handheld/mobile devices
Competent with computers, email, virtual platforms, and Microsoft Office based programs
Ability to type for extended periods
Must be able to remain in a stationary position
Ability to operate a vehicle and travel to meet with members around the community; attend meetings and events as required or requested
Must be able to move around the office and/or travel throughout community
Ability to climb stairs or navigate uneven terrain in community and home environments
Ability to lift, carry, push, or pull up to 20–25 pounds (e.g., laptop bag, forms, mobile equipment)
Ability to bend, reach, and conduct in-person visits in non-traditional environments
Commitment to maintaining patient confidentiality and adhering to ethical standards in healthcare practice
Ability to maintain professionalism and safety in diverse environments
Benefits
Medical, Dental, & Vision Benefits: we cover up to 100% of your premium and 50% of your dependents depending on the plan
Prioritize your mental health with unlimited therapy sessions funded 100% by Titanium Healthcare
Flexible Spending, Health Savings & Dependent Care Accounts
Life/AD&D insurance funded 100% by Titanium Healthcare