Job Description

Community Health Choice, Inc. (Community) is a non-profit managed care organization (MCO), licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 94 hospitals, Community serves over 400,000 Members with the following programs:

* Medicaid State of Texas Access Reform (STAR) program for low-income children and pregnant women

* Children’s Health Insurance Program (CHIP) for the children of low-income parents, which includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR

* Health Insurance Marketplace Plans that offer individual health coverage that includes preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre-existing conditions.

* Community Health Choice (HMO D-SNP), a Medicare Advantage Dual Special Needs plan for people with both Medicare and Medicaid that combines Medicare Part A and Part B benefits, Medicare Part D prescription drug coverage, and Medicaid benefits with additional health benefits like dental, vision, transportation, and more.

Improving Members' experiences is at the heart of every Community position. We strive every day to make sure that our Members have access to the high-quality health care they need and deserve.

Community is accredited by URAC for its health plan operations. We offer care management programs for asthma, diabetes, and high-risk pregnancy. An affiliate of the Harris Health System (Harris Health), Community is financially self-sufficient and receives no financial support from Harris Health or from Harris County taxpayers.

Skills / Requirements

JOB SUMMARY

The New Member Clinical Coordinator will play a crucial role in assessing new enrolled STAR+PLUS members and providing excellent support though overflow call management. This compassionate New Member Clinical Coordinator is responsible for overall management of member's case within the scope of licensure; provides direction to clinicians participating in the member's case in accordance with applicable state law and contract; initiate and revises the member's care plan to meet the member's needs, with the goal of optimizing member health care across the care continuum. The New Member Clinical Coordinator will perform telephonic assessments as mandated by state and federal regulations.

JOB SPECIFICATIONS AND CORE COMPETENCIES

  • Assess, plan, and implement care strategies that are individualized by member and directed toward the most appropriate, lease restrictive level of care.
  • Identify and initiate referrals for social service programs, including financial, psychosocial, community and state supportive services.
  • Initiate care plan to ensure to ensure that care is provided at the beginning.
  • Communicate with all stakeholders the required health-related information to ensure quality coordinated care and services are provided expeditiously to all members.
  • Perform telephonic clinical assessments for the identification, evaluation, coordination and management of member¿s needs, including physical health, behavioral health, social services and long-term services and supports.
  • Identify members for high-risk complications and coordinates care in conjunction with the member and the health care team.
  • Identify members with chronic illnesses, co-morbidities, and/or disabilities.
  • Assists in meeting member needs by referring members to internal and external resources.
  • Address member concerns, provide information, and facilitate problem resolution.
  • Provide efficient and professional support for overflow calls for assigned Service Coordination team and Service Coordination Hotline as needed, ensuring timely and accurate responses to member inquiries.
  • Collaborate with other team members to ensure seamless call handling and quality service delivery.
  • Generate and submit necessary reports and documentation in compliance with organizational and regulatory requirements.
  • Provide input and/or data to direct supervisor/manager related to any internal or external mandatory audit or reporting.
  • Serve as mentor, subject matter expert or preceptor to new staff. Involved in process improvement initiatives.
  • Assist in problem solving with providers, claims or service issues. People/Team Development.


Other duties as assigned. Essential functions listed are not necessarily exhaustive and may be revised by the employer, at its sole discretion.


QUALIFICATIONS:

  • Education/Specialized Training/Licensure: Requires a current unrestricted LVN or RN license in Texas.
  • Work Experience (Years and Area): 2-4 years nursing experience triaging and working with individuals with chronic illnesses, co-morbidities, and/or disabilities in a Service Coordinator or Case Management
  • Experience in long-term care, home health, hospice, public health, or assisted living.
  • Software Proficiencies: Microsoft Office, Clinical documentation platforms, Internet

Application Instructions

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