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Field Care Coordinator - ALTCS - Coconino County
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Full-time
- The Field Care Coordinator will be the primary care manager for a panel of members with low-to-medium complexity medical/behavioral needs.
- 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
- Support proactive discharge planning and manage/coordinate Care Transition following ER visit, inpatient or Skilled Nursing Facility (SNF) admission
- 2+ years of case management experience serving members determined to have a Serious Mental Illness (SMI)
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