Under general supervision from the Manager, Transitions of Care, the Nurse Liaison, Health Homes and Whole Person Care is responsible to meet the day-to-day care coordination needs between the Alliance and contracted Community Based Care Management Entities (CB-CMEs) for the Health Home Pilot and Alameda County’s Whole Person Care initiative. The Nurse Liaison, Health Homes and Whole Person Care is also responsible for coordinating medical, social and or behavioral health care needs with Alliance contracted providers for members enrolled in the Pilot.
Principal responsibilities include:
• Establish and maintain effective, ongoing relationships with CB-CME staff, and participating providers (including office staff)
• Work closely with Medical Director, Project Manager, Special Projects Social Worker and other Alliance staff involved in Health Homes and Whole Person Care projects to make sure that clinical and administrative support is provided to CB-CME’s and members in a timely and high quality manner. Help identify which CB-CME’s need additional support and training and then, with the assistance of the Special Projects team, create a development plan for those teams.
• Provide telephonic, email, or face-to-face coordination and program support to CB-CME staff to help meet the treatment/care plan goals for their patients . This may include problem solving around authorizations, referrals, prescriptions, timely notification of acute care utilization and transfer of clinical notes and discharge summaries.
• Audit and review CB-CME processes, documents, and measures for completion and quality. This includes reviewing and giving feedback on their comprehensive risk assessments and their Health Action Plans. Provide technical assistance and consultation for teams trying to refine processes, documents, and measures.
• Document care coordination activities, and follow up actions in a timely manner according to Alliance policies and regulatory standards in the care management systems independently and in coordination with case managers and other team members.
• Organize and participate in clinical case conferences and meetings with CB-CME case managers, Providers, Alameda County Whole Person Care staff, and/or Alliance staff in order to support effective care coordination and comprehensive care.
• With the help of the project manager and medical director, help organize and facilitate monthly meetings for the CB-CME’s for them to discuss challenges and best practices. Help identify and bring in local experts for education/technical assistance when gaps in knowledge are identified.
• Demonstrate a comprehensive understanding of coverage and benefits in order to promote appropriate service utilization and increase participant, member, and patient knowledge and satisfaction. Also demonstrate an understanding of the grievance and appeals process and be able to help members navigate the process.
• Recognize and resolve continuity of care issues or other problem areas promptly.
• Educate and answer inquiries from participants, patients, and members and/or their family members about benefits, services, eligibility and referrals with a positive and professional approach, promoting participant, patient, and member satisfaction and retention.
• When needed, work directly with members, by phone or face-to-face, to answer questions and to assist with care coordination and referrals.
ESSENTIAL FUNCTIONS OF THE JOB
· Communicate with members and providers to ensure coordination of services for members.
· Maintain case management records.
· Build and maintain effective relationships with members and designated families or caregivers.
· Work with CB-CME’s to develop appropriate member assessments and care plans.
· Serve as a clinical resource to internal and CB-CME staff, and members, as needed.
· Perform writing, administration, analysis, and report preparation.
· May train staff.
· Develop relationships with appropriate community resources to help support members
· Provide direction to staff members and teams tasked with coordination activities for health plan members Comply with the organization’s Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.
· Constant and close visual work at desk or computer.
· Constant sitting and working at desk.
· Constant data entry using keyboard and/or mouse.
· Extensive typing required.
· Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person.
· Travel to Care Facilities and/or Hospitals as needed
· Frequent lifting of folders and other objects weighing between 0 and 30 lbs.
· Frequent walking and standing.
· Occasional driving of automobiles.
EDUCATION OR TRAINING EQUIVALENT TO:
· Active California Registered Nurse License, Nurse Practitioner
· Have a cleared TB test prior to or within seven days of hire.
· Current CPR and first aid card prior to or within six months of hire is preferred.
MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:
· Minimum three years healthcare or customer service experience in the healthcare field, preferably in a health plan setting and a working knowledge of medical and insurance terminology.
· Minimum one year experience in care delivery or coordination in an outpatient clinic, office, home care or inpatient setting including care plan development, care coordination and discharge planning.
· Must have knowledge of acute and chronic medical and behavioral health related topics.
· Experience in a safety net setting preferred
· Knowledge of local resources preferred
SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):
· Knowledge of and experience with the underserved population preferred
· Knowledge of and experience with community and other resources
· Experience in a medical/public health setting preferred
· Ability to prioritize case load
· Ability to make thoughtful decisions and exercise sound judgment.
· Ability to analyze and synthesize UM and care coordination information.
· Experience with case management preferred.
· Experience with planning, implementing, and evaluating clinical and disease prevention programs preferred.
· Background in population-based community health assessment and interventions.
· Ability to work effectively in a multidisciplinary team
· Ability to communicate effectively, both verbally and in writing.
· Possess flexibility and creativity.
· Familiarity with programmatic and clinical research strategies in managed care settings preferred.
· Experience in use of various computer system software as well as Windows, Microsoft Word, Excel, Outlook, and PowerPoint.