D-SNP Care Coordinator

Central Coast Hourly Range: $26.30 - $36.82 per hour

While candidates from anywhere in California are welcome to apply, there is a strong preference for those who reside on the Central Coast (Ventura, Santa Barbara, San Luis Obispo, Monterey and Santa Cruz Counties). This role may offer opportunities for remote work; however, familiarity with and proximity to our local customers is valued.

Job Summary

The D-SNP Care Coordinator is a non-licensed, non-clinical team member who plays a key role in supporting the delivery of Care Management services to eligible Dual Eligible Special Needs Plan (D-SNP) members. This position is responsible for member outreach, engagement, care coordination support, and ongoing follow-up activities for assigned members, including non-responders, members who decline care management services, and members requiring continued outreach and engagement. The Care Coordinator supports continuity of care by addressing non-clinical barriers, facilitating referrals and community resource connections, coordinating logistics, and collaborating closely with RN Care Managers and Social Workers. This role serves as an important link between members, providers, and the interdisciplinary care team to promote member engagement and access to needed services.

Key responsibilities include:

1. Member Outreach and Enrollment

• Conducts telephonic outreach to identify eligible members and obtains consent for enrollment into Care Management programs.
• Supports the completion of Health Risk Assessments (HRAs) by phone and manages both inbound and outbound call queues to facilitate member engagement.

2. Care Coordination and Logistics Support

• Assists RN Care Managers and Social Workers by scheduling medical, behavioral health, and LTSS appointments.
• Arranges transportation, prepares and sends member materials, and facilitates warm handoffs to providers and community-based resources.

3. Documentation and Tracking

• Tracks referrals and post-discharge follow-ups to ensure continuity of care.
• Maintains accurate logs and timely documentation in the care management system to meet regulatory and internal turnaround time standards.

4. Interdisciplinary Team Coordination and Escalation

• Coordinates Interdisciplinary Care Team (ICT) meetings, including scheduling, preparing agendas, and taking brief notes.
• Identifies and helps resolve non-clinical barriers within scope and escalates clinical or complex psychosocial concerns to licensed Care Management staff per established protocols.

Duties and Responsibilities

1. Member Outreach and Enrollment

• Conduct telephonic outreach for D-SNP Care Management (CM) program enrollment/engagement; schedule appointments, coordinate referrals, and assist with day-to-day care coordination between teams.
• Manage an assigned population of members requiring ongoing outreach, engagement, and follow-up activities, including non-responders, members who decline enrollment, and members requiring additional outreach attempts.
• Call members to check their well-being and, when appropriate, reach authorized representatives/family for coordination.
• Provide follow-up calls to support adherence to provider recommendations (e.g., medications, imaging, labs, specialist visits).
• Assist members with completing health surveys (e.g., plan surveys, HRA outreach as allowed by protocol).
• Follow up with members receiving care management/coordination services to maintain engagement.
• Mail educational materials and other pertinent information; generate, mail, and process post-program satisfaction surveys and conduct brief follow-up calls as needed.
• Advocate for members while respecting individual values and preferences.

2. Care Coordination and Logistics Support

• Respond promptly to inbound calls, place outbound calls to members, providers, and internal staff for status updates and coordination.
• Work closely with CM RNs, Social Workers, Population Health, Pharmacy, PCPs, and other team members to address member needs and close loops.
• Collaborate with internal and external care teams to coordinate care across settings throughout the healthcare continuum.
• Connect members to community resources to address social needs (SDOH) and other assistance as appropriate.
• Assist with tasks from the member-centered care plan and monitor adherence in collaboration with the clinical team.
• Refer members to specialized programs (e.g., CCS, TCRC, County Behavioral Health, CS, palliative care, SW, Public Health,) as directed.
• Communicate changes in member status promptly to the assigned clinician.

3. Documentation and Tracking

• Organize, schedule, track, and monitor member contacts and outreach activities.
• Submit accurate documentation and reports on time; adhere to departmental protocols for electronic data entry and form completion.
• Respond promptly and professionally to emails, calls, and other communications; maintain professional interactions with members, providers, and staff.

4. Interdisciplinary Team Coordination and Escalation

• Participate in case conferences/ICT touchpoints and care-planning discussions as requested (support role).
• Escalate clinical or complex psychosocial concerns to CM RN or Social Worker per protocol; notify supervisor of any conflicts or challenges with members or providers.
• Follow policies, procedures, and performance standards; attend and participate in required meetings/trainings.
• Protect confidentiality and comply with HIPAA and all privacy requirements.
• Perform other duties as assigned.

Knowledge/Skills/Abilities

• Member Engagement & Communication: Demonstrates strong verbal communication using plain language, active listening, and teach-back techniques. Maintains professional phone etiquette for inbound and outbound calls, including voicemail follow-ups.

• Telephonic Outreach & Call Management: Effectively manages call queues and performs a variety of outreach activities, including program enrollment and consent calls, HRA reminders, appointment scheduling, and brief well-being check-ins.

• Care Coordination & Resource Navigation: Coordinates appointments, transportation, referrals, and warm handoffs. Connects members to appropriate community resources to address social needs, including Social Determinants of Health (SDOH).

• Documentation & Data Accuracy: Accurately records member contacts, referrals, scheduling information, and outcomes in a timely manner. Maintains organized tracking logs and adheres to department protocols for data entry.

• Privacy & Ethical Standards: Maintains strict confidentiality in accordance with HIPAA and organizational privacy policies. Upholds professional boundaries and follows consent and Release of Information (ROI) procedures.

• Time Management & Task Prioritization: Effectively manages a dynamic caseload and outreach list, meets productivity standards and regulatory turnaround times, and adapts to shifting priorities as needed.

• Problem Solving & Issue Escalation: Identifies and addresses routine barriers to care within the scope of the role. Appropriately escalates clinical or complex psychosocial issues to RN Care Managers or Social Workers and notifies supervisors of conflicts or concerns.

• Teamwork & Interdisciplinary Collaboration: Works cooperatively with Care Management RNs, Social Workers, Population Health staff, Pharmacy, PCP offices, and other internal and external partners. Actively participates in case conferences and Interdisciplinary Care Team (ICT) touchpoints as appropriate.

• Cultural Humility & Language Access: Engages respectfully with members from diverse cultural and socioeconomic backgrounds. Utilizes interpreter services appropriately to support language access. Bilingual skills are highly valued.

• Customer Service & De-escalation: Maintains a calm, supportive, and professional demeanor during all interactions. Diffuses member or provider frustration and clearly communicates next steps for resolution.

• Technology Proficiency: Demonstrates proficiency with telephonic systems, care management platforms, and standard office software, including email, word processing, and spreadsheets. Ensures accurate and timely data entry.

Education and Experience

Education:

• Associate's degree in business, health science, healthcare, health management, or a related field, or three (3) years of experience as a Certified Medical Assistant, Certified Nursing Assistant, or Licensed Vocational/Practical Nurse in place of an associate's degree or 2-3 years equivalent work experience.

• Completion of an accredited Medical Assistant or Medical Office Professional program may substitute for 2 years of work experience.

Experience:

• At least 2-3 years of full-time or equivalent experience in a medical office, health plan, managed care organization, hospital (ED or inpatient), skilled nursing facility, clinic, or another healthcare setting, working directly with patients, members, providers, and/or clinicians.

• Experience working with vulnerable populations (e.g., seniors, people with disabilities, behavioral health needs, homelessness, or significant social needs).

Preferred:

• Bilingual in Spanish preferred.