Medicare Transition Coordinator - Long Term Services & Support LTSS Michigan

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At AmeriHealth Caritas, we're passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we'd like to hear from you.

Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

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Responsibilities:

;Medicare LTSS Transition Coordinator is responsible for managing a patient's successful transition from hospital to home, or alternate location and is accountable for developing, implementing and evaluating comprehensive transitional care interventions for members. The Medicare LTSS Transition Coordinator is a member of the Integrated Care Team. Under the supervision of the Medicare LTSS Operations Supervisor, the Medicare LTSS Transition Coordinator is responsible for managing the post-acute care of members that are at risk for poor health outcomes, frequent emergency room visits and hospital readmissions. This position will work with complex and varied patients and situations.;

Provide transition of care coordination to members:

• 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 patient/family education needs through assessment to ensure that patient/family members have adequate information to participate in transition planning.

• Critically evaluates and analyzes physical and psychosocial assessment data.

• Performs medication reconciliation and partners with providers to address discrepancies, contraindications and/or side effects which present as barriers to medication adherence.

• Assesses complexity of care needs and potential/actual issues or gaps in care.

• Conducts health literacy assessment using a defined industry proven tool.

• Interprets screening and selective laboratory/diagnostic tests.

• Initiates and maintains communication and collaboration with physicians, social workers, Integrated Care team members, other care giving disciplines, and patients/families to develop, implement and evaluate a transition plan of care for each patient.

• Acquires and assimilates new and existing information into care plan delivery to meet the needs of the member.

• Utilizes resources, including home and community based waiver services to maximize the health care benefit to the member.

• Arranges post-discharge medical and community referrals for patients with health problems requiring further evaluation and/or additional services.

• Identifies, tracks and conducts root cause analyses on 30-Day readmissions to address programmatic and system wide improvements.

• Participates in clinical performance improvement activities to achieve set goals.

• Develops routine report materials and delivers presentations/reports to internal and external stakeholders, as required.

• Travels throughout the service areas as required to perform duties and assignments.

• Interfaces with Medical Directors, and other Integrated Care Team participants on the development of care management treatment plans.

• May also assist in problem solving with providers, claims or service issues.

• May direct the work of other licensed and unlicensed professionals in coordinating services for a member by, assigning appropriate tasks, verifying and interpreting member information obtained, conducting additional assessments, as necessary, to develop, monitor, evaluate and revisit the member's care plan to meet the member's needs.

• Maintains a current knowledge of CMS and DHHS requirements along with required licensure and required training.

• Adheres to AmeriHealth Caritas policies and procedures.

• Creates and supports an environment with fosters teamwork, cooperation, respect and diversity.

• Instills work culture of continuous process improvement, innovation and quality.

• Demonstrates and supports commitment to corporate goals and objectives.

• ;Performs other related duties and projects as assigned.

; Education & Qualifications:;

• 1 to 3 years experience with transition of care and/or care coordination activities.

• Bachelor's Degree required.;

• Active and unrestricted Registered Nurse licensure (R.N.) required.

• Proficient PC skills with Microsoft Office Suite (Word, Excel, etc.) and proficiency in working within Electronic Health Records

• Strong knowledge of Medicare/MMP/DSNP Integrated Care Management programs

• Ability to communicate with beneficiaries who have medical needs and may have communication barriers, such as those who may require an interpreter, including sign language, who use assistive technology to communicate.

• Ability to work independently or as a team.

• Ability to maintain positive relationship with both internal and external customers.

• Field experience (home health, etc.) preferred.

• 50% local travel required and mileage reimbursed will be provided.

Diversity, Equity, and Inclusion

At Amerihealth Caritas, everyone can feel valued, supported, and comfortable to be themselves. Our commitment to equity means that all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. We stand together to speak out against injustice and to break down barriers to support a more inclusive and equitable workplace. Celebrating and embracing the diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve.

We keep our associates happy so they can focus on keeping our members healthy.

Our Comprehensive Benefits Package

Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.