Virginia Premier Health Plan Complex Care Coordinator II in Bristol, Virginia

About Us

Don’t just find a job, find your WHY at a purpose-driven organization; discover a career at Virginia Premier.

By blending quality benefits, affiliating with the world-renowned VCU Health System and offering career-advancing development programs, we allow our employees to focus on the meaningful work of improving and saving the lives of more than 200,000 people throughout the state of Virginia.

At Virginia Premier, we are building an industry leading health care organization through dedicated teams that have heart, provide top-notch quality member services and embrace our mission of inspiring healthy living within the communities we serve. Our vision is to connect people to innovation, quality and affordable health care for all phases of life.

If this sounds like you, read on!

Overview

Under the supervision of the Manager, Complex Care Coordinator IIs provide primary care management to members who have complex medical and/or behavioral health needs and are considered part of the Vulnerable Subpopulation [including members with significant mental illness and members with waivers for intellectual disability (ID), developmental disability (IFDDS), and/or requiring day support (DS)]. These care coordinators focus on high risk Medicaid and/or dual-eligible members (adults and children) who are at risk for higher utilization of services, readmissions, and/or transitions. This role is mostly telephonic, but may involve some face-to-face interactions with the member to provide the support needed for ongoing care coordination to enhance quality, improve member outcomes, and encourage appropriate utilization of health services.

Medical Management

Medical Management educates members and empowers them to become active participants in their coordinated health care plans. This team of knowledgeable professionals in their field provide services to include Utilization Review, Medical Outreach, Case Management, Disease Management, Credentialing, Social Work as well as Grievance and Appeals.

Responsibilities

  • Provides primary care management of members who are part of the Vulnerable Subpopulation to include Serious Mental Illness, complex and chronic medical and/or behavioral health conditions, and those receiving the Day Support (DS) or Intellectual Disability (ID) or Individual and Family Developmental Disabilities Support (DD) waivers

  • Conducts time-sensitive, telephonic initial comprehensive assessment of the member’s medical and behavioral health, psychosocial needs, functional status, social history, including health literacy status and deficits, and develops an individualized care plan (ICP) collaboratively with the member, family, caregiver, PCP, and participants of the member’s interdisciplinary care team (ICT)

  • Conducts triggering assessments and updates to the ICP with the member, family or caregiver, the PCP/provider, other health care providers, and the community to maximize health care responses, quality and cost-effective outcomes

  • Conducts annual reassessments with the member with an updated ICP and ICT

  • Conducts face-to-face assessments with the member when appropriate

  • Facilitates communication and coordination between members of the health care team

  • Provides mentoring and oversight to Complex Care Coordinator I staff in the performance of assessments and development of ICPs

  • Educates the member, the family or caregiver, and members of the health care team about treatment options, community resources, insurance benefits, psychosocial concerns, care management , etc., so that timely and informed decisions can be made

  • Collaborates with the member’s ID/DD/or DS case manager to ensure waiver services are in place and appropriate for the member as well as incorporating these elements into the ICP and having the case manager to serve on the member’s ICT

  • Assists the member and their family/caregiver in navigating the health care system

  • Encourages the member to be actively involved in the health care decision-making process

  • Empowers the member to problem solve by exploring options of care, when available, and alternative plans, when necessary, to achieve desired outcomes

  • Encourages the appropriate use of health care services and strives to improve the quality of care and maintain cost effectiveness on a case-by-case basis

  • Performs secondary review of service requests for residential treatment, substance abuse day treatment, and intensive outpatient treatment.

  • Collaborates with UR nurse to manage length of stay based upon medical necessity, community supports, and member’s specific social situation.

  • Provides referrals for brief and immediate crisis intervention (i.e. Adult Protective Services)

  • Collaborates with the transition coordinator to ensure member’s needs are met when undergoing transitions

  • Provides referrals to health-related services such as disease management and health education

  • Assists members who are in crisis

  • Strives to promote member self-advocacy and self-determination

  • Acts as an advocate for a member’s health care needs

  • Participates in VPHP’s ongoing quality improvement process

  • Participates in continuing educational activities as appropriate

  • Participates in care management rounds/meetings

  • Practices in accordance with applicable local, state and federal laws which govern confidentiality and medical information privacy regulations (HIPAA)

  • Leads and conducts regular communications with the member’s chosen ICT

  • Provides oversight and maintenance of the member’s ICP

  • Other duties as assigned

Qualifications

MINIMUM EDUCATION REQUIREMENTS

  • Registered Nurse licensed in the Commonwealth of Virginia (Bachelor degree preferred), OR

  • Licensed Clinical Social Worker in the Commonwealth of Virginia

  • Certified Case Manager preferred

SPECIAL KNOWLEDGE AND/OR SKILLS

  • Bilingual – English and Spanish Preferred

  • Excellent Patient care evaluation skills and the ability to communicate well (written and verbal) with all levels of management, medical staff and employees

  • PC literate with working knowledge of Microsoft Office and various computer software programs

  • Working knowledge of resource options, and experience in making appropriate referrals

  • Strong decision making skills, ability to handle multiple priorities

  • Knowledge of case management fundamentals

  • Some local travel will be required

WORK BACKGROUND/EXPERIENCE

  • Minimum of 2 years clinical experience working with the elderly, disabled, low income/disadvantaged, and/or vulnerable subpopulations

  • Experience in care management, assessment, long-term member/patient care management or community based resource delivery

  • Previous work experience with behavioral health populations is needed

  • Knowledge of community resources preferred.

ElLIGIBILITY REQUIREMENTS

  • Must be willing and able to conform to a background check.

  • Must have positive points on a valid Virginia Driver's License.

PHYSICAL REQUIREMENTS

  • Physicalhealth sufficient to meet the ergonomic standards and demands of the position

All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status. EOE

Our mission is to inspire healthy living within the communities we serve!

Job ID 2018-5399

As an equal opportunity employer, Virginia Premier is committed to a diverse workforce. To ensure non-discrimination and affirmative action for individuals protected by Executive Order 11246, as amended, Section 503 of the Rehabilitation Act of 1973, as amended, the Vietnam Veterans’ Readjustment Act of 1974, as amended, and Title I of the Americans with Disabilities Act of 1990, as amended, Virginia Premier will consider applicants for employment without regard to their race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status. Applicants who require accommodation in the job application process may contact Recruitment at 804-819-5151 for assistance. It is the policy of Virginia Premier Health Plan, Inc., to comply with the requirements of the Drug-Free Workplace Act of 1988. It is a violation of our drug-free workplace policy to use, possess, sell, trade, and/or offer for sale alcohol, illegal drugs or intoxicants in our workplace. Federal law requires all employers to verify the identity and employment eligibility of all persons hired to work in the United States. Virginia Premier participates in E-verify.