Continuum of Care Specialist

Organizational Background:

Northeast Health Partners (NHP) is a mission-driven organization dedicated to delivering high-quality, integrated healthcare services to communities across northeastern Colorado. As the Regional Accountable Entity (RAE) for Region 2 under Health First Colorado (Medicaid), NHP oversees the coordination and delivery of physical and behavioral health services for Medicaid members. We ensure a full spectrum of high quality, whole-person care, promoting member education, preventive services, care coordination, and evidence-based treatments are core to our mission.

Position Summary:

Continuum of Care Care Specialist plays a critical role in managing high-risk and high-priority populations, ensuring effective transitions of care, and leading a team of care coordination staff. This position is responsible for developing and overseeing outreach strategies, coordinating post-discharge follow-ups, and ensuring members successfully connect with medical, behavioral health, and social services. This position will work closely with hospital discharge teams, primary care providers, behavioral health professionals, and community organizations to reduce gaps in care, prevent avoidable hospital readmissions, and improve health outcomes for vulnerable Medicaid members. Strong regional knowledge of state and local resources is essential for success in this role. Must reside in the State of Colorado or be willing to relocate prior to position start date.

Duties Performed:

• Manage and mentor a team of healthcare coordinators, providing guidance and support to ensure effective patient care coordination.
• Building and maintaining strong partnerships with healthcare providers, hospital discharge teams, behavioral health organizations, and community-based services and facilitating collaboration across sectors to enhance resource navigation.
• Analyze and optimize care coordination processes to enhance efficiency and improve patient outcomes.
• Tracking care coordination efforts, documenting patient outcomes and reporting key performance indicators (KPIs) to care coordination and quality leadership staff.
• Work closely with healthcare providers, administrative staff, and community resources to develop connection plans that ensure patients access the necessary services and support.
• Serve as a patient advocate, addressing concerns and ensuring that patients understand their treatment options and health coordination plans.
• Ensure adherence to regulatory standards and best practices in patient care coordination.
• Assist in managing budgets for care coordination services and identify cost-effective solutions to improve patient care.
• Assist patients in navigating the healthcare system, including scheduling appointments, referrals and follow-ups.
• Ensuring timely post-discharge follow-up rates
• Reducing hospital readmission rates among high-risk patients
• Increasing patient engagement in care coordination
• Enhancing access to social supports
• Serve as a point of contact for patients and families, providing information and support regarding treatment options and procedures.
• Maintain accurate patient records and documentation in compliance with privacy regulations.
• Monitor patient care services to ensure quality and safety standards are met.
• Provide education to patients about their conditions and treatment plans, as well as preventive care strategies.
• Identify and connect patients to appropriate community resources and support services. This includes assessing needs, coordinating referrals, facilitating access to services, and following up to ensure successful engagement with housing, transportation, behavioral health, and other essential supports.
• Experience in resource navigation, referrals and community partnerships a must. Strong regional knowledge of community and state resources is essential to effectively navigate available services and build connections that support successful patient outcomes.
• Work closely with healthcare providers, insurance companies, and other stakeholders to facilitate comprehensive care.
• Ability to routinely travel throughout Colorado and Region 2.

KNOWLEDGE/SKILLS/ABILITIES

Education/Credentials:

• Bachelor's degree in healthcare administration, nursing, social work, or related field.
• Certification or licensure preferred

Experience:

• 5 years’ experience working in healthcare coordination, case management, or a similar role preferred.

Knowledge of:

• Medical terminology.
• Healthcare regulations
• State sponsored health plans

Skills/ Abilities to:

• Excellent communication and interpersonal skills
• Strong Organizational and time management skills
• Ability to work independently or as part of a team
• Project management principles, practices, techniques and tools.

Working Conditions:

Work is primarily performed in a standard office environment; however, a hybrid work model may be offered, blending in-office and remote work opportunities based on organizational needs and job requirements. Some meetings will occur at locations outside of the usual work location, including the use of conference and electronic meeting platforms (e.g., Zoom, GoToMeeting). All positions require travel within the counties NHP serves.

SALARY RANGE:

Salary Range: $45,0000.00 - $65,000.00. The base compensation represents the entry point of the range. Actual salaries will vary and may be above or below the range based on factors including but not limited to location, experience, education, licensure, and performance.

Job Type: Full-time

Pay: $45,000.00 - $65,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Health savings account
• Paid time off
• Vision insurance

Schedule:

• Monday to Friday
• Weekends as needed

Application Question(s):

• Do you reside in the State of Colorado or are you willing to relocate prior to position start date?
• Do you have any Certification or Licensure?

Experience:

• Mental health field and service delivery: 5 years (Required)

Work Location: Hybrid remote in Greeley, CO 80631

Salary : $45,000 - $65,000