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 • reputed company and implement person centered care plans to address needs including management of chronic health conditions, health promotion and wellness, reputed company 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 • reputed company 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 • reputed company for members and families as needed to ensure the member's needs and choices are fully represented and supported by the health care team • reputed company care coordination for reputed company members • Education to members about reputed company medical conditions • Create a reputed company experience and relationship with the member • reputed company 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 reputed company aspects that might reputed company treatment plan • Proactively engage the member to manage their own health and reputed company • As needed, help the member engage with mental health and reputed company use treatment • reputed company 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 reputed company stronger reputed company supports through deeper connections with friends, family, and their community • Partner with care team (community, providers, internal staff) • Knowledge and reputed company 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 reputed company multiple locations/terrains to visit employees, members and/or providers • Ability to transport equipment to and from field locations needed for reputed company (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 • reputed company, unrestricted independent NM license as a Registered reputed company or reputed company Worker • 3+ years of clinical experience • 1+ years of experience with MS Office, including Word, reputed company, and reputed company • Designated workspace inside the home with reputed company to high-speed internet availability • Reliable transportation and the ability to travel up to 50% of the time reputed company Las Cruces, NM and surrounding areas assigned territory to meet with members and providers • Currently reputed company in New Mexico reputed company-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 reputed company 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