Perform outreach to Medicaid members both in person and telephonically to coordinate care, access to services, transition on and off the plan, and to achieve person-centered care plan goals. Conduct in-person member visits in community settings, such as homes, hospitals and physician offices to introduce and engage members in care planning and achieving care plan goals. Facilitate collaboration across the member s care team to achieve care plan goals. Address social determinants identified in the care plan.
- Perform outreach calls and field visits to members to convey the programs offered, assess members, and create a care plan.
- Develop person-centered care plans and goals with the member and other care team members as required.
- Offer proficient knowledge of community resources to eliminate barriers to care and provide follows up on progress toward meeting goals.
- Coach Medicaid members in effective management of their chronic health conditions and self-care, i.e. Asthma, PDI/ PQI, diabetes, HIV, etc.
- Collaborate and track LTSS members home visits, assessments, and discharges.
- Assist members in accessing services, taking into account social determinants of health.
- Help members understand their care plans and instructions.
- Actively collaborate with other care team members and support care management interventions including discharge plan review.
- Engage new enrollees: educate them regarding Medicaid benefits and review health risk assessments.
- Remove barriers to assist members in meeting care plan goals, including making doctors appointments, referrals to internal and external resources, and setting up transportation.
- Collaborate with quality management team(s) as needed to ensure gaps in care are addressed.
- Bachelor s degree, preferably in a health-care related field
- A minimum of 3 years experience in health care industry, or other related activities required
- Additional years of experience may be considered in lieu of educational requirements required
- Proficient in medical terminology required
- Proficient in community resources and eliminating barriers to care required
- Experience working in a multicultural setting required
- Spanish/Cantonese/Punjab/Korean speaking preferred
- Excellent verbal and written communication skills required
- Excellent customer service qualities required
- Ability to physically travel to work sites required
- Computer proficiency required. Word, excel required
- Detailed oriented and strong organization skills required
- Requisition ID: 191FQ
We are committed to leveraging the diverse backgrounds, perspectives and experiences of our workforce to create opportunities for our people and our business. We are an equal opportunity/affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or any other characteristic protected by law.
Depending on factors such as business unit requirements, the nature of the position, cost and applicable laws and regulations, EmblemHealth may provide work visa sponsorship for certain positions.