Clinical Care Coordinator, DSNP

About the position Responsibilities • Engage members face-to-face and/or telephonically to complete a comprehensive needs assessment, including assessment of medical, behavioral, functional, cultural, and socioeconomic needs • Develop and implement person centered care plans to address needs including management of chronic health conditions, health promotion and wellness, social determinants of health, medication management and member safety in alignment with evidence-based guidelines • Partner and collaborate with internal care team, providers, and community resources/partners to implement care plan • Provide education and coaching to support member self-management of care needs and lifestyle changes to promote health • Support proactive discharge planning and manage/coordinate Care Transition following ER visit, inpatient or Skilled Nursing Facility (SNF) admission • Advocate for members and families as needed to ensure the member's needs and choices are fully represented and supported by the health care team • Provide care coordination for complex members • Education to members about complex medical conditions • Create a positive experience and relationship with the member • Practice cultural sensitivity and cultural competence in daily care • Learn and listen to member needs and barriers to help promote self-advocating • Collaborating with clinical team of social aspects that might impact treatment plan • Proactively engage the member to manage their own health and healthcare • As needed, help the member engage with mental health and substance use treatment • Provide member education and health literacy on community resources and benefits to encourage self sufficiency • Support member to engage in work or volunteer activities, if desired, and develop stronger social supports through deeper connections with friends, family, and their community • Partner with care team (community, providers, internal staff) • Knowledge and continued learning of community cultures and values • Conduct Comprehensive Needs Assessment (CNA) • Ability to transition from office to field locations multiple times per day • Ability to navigate multiple locations/terrains to visit employees, members and/or providers • Ability to transport equipment to and from field locations needed for visits (ex. laptop, etc.) • Ability to remain stationary for long periods of time to complete computer or tablet work duties Requirements • Bachelor's degree OR 2+ years of relevant health care experience • Current, unrestricted independent NM license as a Registered Nurse or Social Worker • 3+ years of clinical experience • 1+ years of experience with MS Office, including Word, Excel, and Outlook • Designated workspace inside the home with access to high-speed internet availability • Reliable transportation and the ability to travel up to 50% of the time within Las Cruces, NM and surrounding areas assigned territory to meet with members and providers • Currently reside in New Mexico Nice-to-haves • Master's Degree or Higher in clinical field • Commission for Case Manager (CCM) certification • 1+ years of community case management experience coordinating care for individuals with complex needs • Experience with DSNP population • Experience with Medicare • Experience working in team-based care • Background in Managed Care Benefits • Comprehensive benefits package • Incentive and recognition programs • Equity stock purchase • 401k contribution Apply tot his job Apply To this Job