Field Care Coordinator (HIDE SNP) - Berrien County, MI and Surrounding

About this role

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The Field Care Coordinator- HIDE SNP is an essential element of an Integrated Care Model and is responsible for establishing a set of person-centered goal-oriented, culturally relevant, and logical steps to ensure that the person receiving LTSS receives services in a supportive, effective, efficient, timely and cost-effective manner. Care coordination includes case management, disease management, discharge planning, transition planning, and addressing social determinants of health and integration into the community. This position is Field Based with a Home-Based office

The expected travel time for member home visits is typically 75% within a 50-mile radius and/or 50-minute drive from your home pending business needs. If you reside in or near Berrien County, MI or surrounding areas , you will have the flexibility to telecommute* as you take on some tough challenges. Primary Responsibilities: Develop and implement care plan interventions throughout the continuum of care as a single point of contact Communicate with all stakeholders the required health-related information to ensure quality coordinated care and services are provided expeditiously to all members Advocate for persons and families as needed to ensure the patient's needs and choices are fully represented and supported by the health care team Assess, plan, and implement care strategies that are individualized by the individual and directed toward the most appropriate, least restrictive level of care Identifies problems/barriers to care and provide appropriate care management interventions Identify and initiate referr

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