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 Star+Plus (LTSS) Service Coordinator Level 1 is responsible for overall management of member's case within the scope of licensure; provides supervision and direction to non-RN clinicians participating in the member's case in accordance with applicable state law and contract; develops, monitors, evaluates, 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.
JOB SPECIFICATIONS
Responsible for performing telephonic or face-to-face 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.
Identifies members for high-risk complications and coordinates care in conjunction with the member and the health care team.
Manages members with chronic illnesses, co-morbidities, and/or disabilities, to insure cost effective and efficient utilization of health benefits.
Obtains a thorough and accurate member history to develop an individual care plan.
Establishes short- and long-term goals in collaboration with the member, caregivers, family, natural supports, physicians; identifies members that would benefit from an alternative level of care or other waiver programs.
The RN has overall responsibility to develop the care plan for services for the member and ensures the member's access to those services.
May assist with the implementation of member care plans by facilitating authorizations/referrals for utilization of services, as appropriate, within benefits structure or through extra-contractual arrangements, as permissible.
Interfaces with Medical Directors, Physician Advisors and/or Inter-Disciplinary Teams on the development of care management treatment plans.
May also assist in problem solving with providers, claims or service issues.
Directs and/or supervises the work of any LPN/LVN, LSW, LCSW, LMSW, and other licensed professionals other than an RN, in coordinating services for the member by, for example, assigning appropriate tasks to the non-RN clinicians, verifying and interpreting member information obtained by these individuals, conducting additional assessments, as necessary, to develop, monitor, evaluate, and revise the member's care plan to meet the member's needs, and reviewing and providing input on the non-RN clinicians' performance on a regular basis.
Assists in meeting member needs by referring members to internal and external resources.
Provide follow up with internal and external resources, providers, and state programs.
Marginal Functions
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.
Actively contributes to achievement of departmental goals, as identified in Department¿s annual business plan, including specific departmental process improvement plans and other duties as assigned.
Qualifications
Education/Specialized Training/Licensure: Requires a current unrestricted RN license or NP in Texas required.
BSN, CCM preferred.
Work Experience (Years and Area): 3-5 years nursing experience working with individuals with chronic illnesses, co-morbidities, and/or disabilities in a Service Coordinator, Case Management, or similar role.
1 year experience working with population who receive waiver services.
1 year experience working with persons with disabilities/chronic conditions and Long-Term Services & Supports.
Management Experience (Years and Area): N/A
Software Proficiencies: Microsoft Office, Clinical documentation platforms, Internet
Other: Local travel required
Reliable transportation with valid driver's license with good driving record
Seniority level
Mid-Senior level
Employment type
Full-time
Job function
Other
Industries
Insurance
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