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**Role Overview:** The Care Coordinator assists members who are appropriate for care coordination and case management services in achieving their optimal level of health.; The Care Coordinator must have relevant experience and education to work with enrollees with complex health, behavioral health, long-term services and supports, and/or psychosocial needs.

Work Arrangement:

+ Remote - This is a remote, field-based position that requires the candidate to reside in or near Macomb County, Michigan, to facilitate regular in-person meetings with members.

Responsibilities:

+ Provides access to a single point of contact for all questions or inquiries

+ Conducts assessments with Enrollees and/ or their caregiver

+ Develops an Individualized Care Plan that is periodically reviewed and updated

+ Provides disease self-management and coaching

+ Conducts medication review, including reconciliation during transitions of care settings

+ Provides periodic monitoring of health, functional, and mental status, along with pain and fall screening

+ Ensures the provision of services in the least restrictive setting and transition support across and between specialties and care settings

+ Connects Enrollees to services that promote community living and help to delay or avoid nursing facility placement

+ Coordinates with social service agencies (e.g., local departments of health, social services, and community-based organizations) and the referral of Enrollees to state, local, and/or other community resources

+ Collaborates with nursing facilities to promote the adoption of evidence-based interventions to reduce avoidable hospitalization, management of chronic conditions, medication optimization, fall and pressure ulcer prevention, and the coordination of services beyond the scope of the nursing facility benefit

Education & Experience:

+ A bachelor's degree in a health-related field and a current and unrestricted Registered Nurse (RN) license.;

+ Minimum of 1 year of social services and/or clinical experience working with complex populations, including those with physical health, behavioral health, long-term services and supports, and/or psychosocial needs

+ Minimum of 3 years of case management experience preferred

+ 3 years of professional practice experience required

+ Certification as a Case Manager or a Community Health Worker is preferred

Licensure:

+ A current and unrestricted RN/SW licensure in Michigan.;

+ Valid driver’s license with car insurance required

As a company, we support internal diversity through:

Recruiting. We are an equal opportunity employer. We do not discriminate on the basis of age, race, ethnicity, gender, religion, sexual orientation, or disability. Our inclusive, equitable approach to recruiting and hiring reinforces our commitment to DEI.