Care Coordinator - SNBC

As a Care Coordinator – SNBC, you will be responsible to coordinate services across the continuum of care to assist members with recovery and resiliency as they work to address their complex physical health conditions, mental health conditions, substance use disorders (SUD), and social service needs. Collaborate with members and providers to engage, assess, develop, implement, coordinate, monitor and evaluate member centered care plans for identified needs. Refer members to providers, county and community agencies, and coordinate care with those same providers and agencies. Partner with the agencies to coordinate the provision of services for UCare members, including such things as establishing a primary care clinic, helping to facilitate care conferences as needed, and to assess and evaluate what combination of services is going to uniquely meet the members’ needs.

• Provide member centered in-person and telephonic care coordination for members with mental health, SUD and medical conditions that focuses on recovery and resiliency for all UCare SNBC product lines (integrated and non-integrated).

• Engage members in ongoing care coordination using evidence-based, member centered practices including Motivational Interviewing and Trauma Informed Care.

• Conduct in-person and telephonic assessments to identify individual needs including addressing social determinant of health needs and actively linking members to appropriate resources available in their community. Appropriately utilize interpreter services. Identify and monitor member needs, including needed preventive medical care, and significant changes in condition which may warrant early intervention.

• Promote the establishment of a strong Primary Care Clinician relationship and an overarching individualized care plan which takes into account the member’s needs and priorities. Develop and implement member centered care plan, in collaboration with member/family/caregiver that is appropriate to the member’s needs. Monitor and evaluates effectiveness of the care plan and modify as necessary. Incorporate ethnic and culturally appropriate approaches to care planning. Work with the member to establish culturally congruent services whenever possible. Encourage the connection to community resources and engagement to meet each member’s individual needs.

• Collaborate with members and/or family members, mental health and SUD clinicians, psychiatrists, primary care providers, clinic staff and other relevant providers in the continuum of care to assure appropriateness of service that meets member needs and supports desired outcomes.

• Understand, accurately interpret and apply relevant contractual requirements, policies, procedures and regulations for members which care coordination is a provided service.

• Meet and maintain all established caseload and performance metrics. Present information on assigned members at assessment conferences and case reviews. Enter member information in the clinical documentation system. Complete accurate, thorough and timely documentation.

• Ensure safe transitions when members move from one setting to another (i.e. being discharged from a hospital or residential facility). Ensure the plan of care is communicated between the sending and receiving settings for both planned and unplanned transitions. Anticipate the member’s needs and coordinate with care providers to ensure that the member has a soft and successful landing.

• Develop and maintain a comprehensive knowledge of member benefits for each product; understand, implement, and support the Evidence of Coverage, and follow organization policies as they relate to member benefits.

• Provide information to members and providers regarding plan benefits, services and resources. Help facilitate the appropriate care on behalf of, and in conjunction with, the member.

• Collaborate with multidisciplinary staff to bring perspective based on discipline and experience.

• Provide back-up coverage for other care coordinators as assigned.

• Must have reliable transportation to travel throughout designated counties in Minnesota.

• Other projects and duties as assigned.

Education

RN, LP, LPCC, LMFT, LSW, MSW, LGSW, LISW or LICSW with requisite experience. Current and unrestricted Minnesota license required.

Required Experience

Two year's experience in care coordination/case management across the continuum of health care (hospital, clinic, community mental health, residential care, etc.) with primary emphasis in working with complex social, mental health, SUD and medical needs.

Preferred Experience

RN, LP, LPCC, LMFT or LICSW candidate with 2 years’ experience in case management. Dually licensed as LADC. Experience working with state and federally funded programs. Experience in an HMO or MCO. Experience working in managed care, government programs (Medicare, Medicaid and other State Public Programs), diverse populations, or with mental health and substance use disorders. Bilingual. Proficiency in at least one of the following languages in addition to English preferred: Hmong, Spanish, Russian, Somali or Vietnamese.

THE UCARE DIFFERENCE

The UCare difference is our people power – employees actively working on the behalf of our members to get them access to the health care they need. We value and respect each individual's ideas and contributions, and provide the freedom to grow both personally and professionally. We are centrally located, and offer onsite education, equipment and wellness resources, and a myriad of volunteer activities. If you're looking for an inclusive environment that celebrates your people power, helps you build on your strengths and gives you the opportunity to truly make a difference, we invite you to apply.

As an Equal Opportunity/Affirmative Action Employer, we welcome and employ a diverse employee group committed to meeting the needs of UCare, our members, and the communities we serve.

JOB POST DATE: 11/1/2023