Care Coordinator; Care Manager - Registered Nurse; RN), Social Worker, or Clinical Counselor

Overview

Community Based Care Coordinator (RN/Social Worker/Clinical Counselor) – Duals Integrated Care – Ohio Mobile

This role is responsible for managing and coordinating care for dual-eligible beneficiaries (Medicare and Medicaid). The position focuses on integrating health services and community resources to improve health outcomes and quality of life for individuals with complex health needs.

• Engage with members in community-based settings to establish an effective care coordination relationship, considering cultural and linguistic needs.
• Serve as a liaison between healthcare providers, community resources, and dual-eligible beneficiaries to ensure seamless communication and care transitions.
• Conduct comprehensive assessments to identify physical, mental, and social needs of dual-eligible individuals.
• Develop and implement individualized care plans based on medical, social, and behavioral health requirements.
• Collaborate with an interdisciplinary care team (ICT) to create holistic care plans addressing medical and non-medical needs.
• Assist members in accessing community resources (housing, transportation, food assistance, social services).
• Educate members about benefits and services under Medicare and Medicaid.
• Provide education to members and families about managing chronic conditions, medication adherence, and preventive care.
• Promote healthy lifestyle choices and self-management strategies.
• Monitor health status and care plan adherence; adjust as necessary.
• Follow up after hospitalizations or significant health events to ensure continuity of care and prevent readmissions.
• Coordinate with primary care physicians, specialists, and other providers to share information and coordinate care.
• Coordinate with community-based organizations, state agencies, and other service providers to avoid duplication of services.
• Participate in care team meetings to discuss progress and address barriers to care.
• Maintain accurate records of member interactions, care plans, and outcomes.
• Collect and analyze data to evaluate effectiveness and identify areas for improvement.
• Advocate for the needs and preferences of dual-eligible beneficiaries within the healthcare system.
• Empower members to participate in their healthcare decisions.
• Assess member satisfaction and address concerns or issues.
• Travel as needed to conduct member, provider, and community visits per program requirements.
• Report abuse, neglect, or exploitation of older adults as a mandated reporter under state law.
• On-call responsibilities as assigned.
• Adherence to NCQA and CMSA standards.
• Perform any other job duties as requested.

• Nursing degree from an accredited nursing program or bachelor’s degree in a healthcare field, or equivalent years of relevant experience.
• Previous experience in nursing, social work, counseling, or health care roles (e.g., discharge planning, case management, care coordination, home/community health management).
• Prior experience in care coordination, case management, or working with dual-eligible populations preferred.
• Medicaid and/or Medicare managed care experience preferred.

• Intermediate proficiency with Microsoft Office (Outlook, Word, Excel).
• Understanding of Medicare and Medicaid programs and community resources for dual-eligible beneficiaries.
• Strong interpersonal and communication skills to engage with members, families, and providers.
• Ability to manage multiple cases and priorities with attention to detail.
• Adherence to ethical standards in professional practice.
• Aware of and sensitive to diverse backgrounds and needs of served populations.
• Decision-making and problem-solving skills.

• Current unrestricted clinical license in the state of practice as a Registered Nurse, Social Worker, or Clinical Counselor (licensure may be required in multiple states based on duties).
• Case Management Certification is highly preferred.
• Valid driver’s license, vehicle, and verifiable insurance required. Conditional employment pending clearance of driver’s license record and insurance verification.
• Influenza vaccination is a requirement for designated positions during…