Health Home Care Coordinator

In 2020 united in a fierce commitment to deliver the highest quality care and exceptional patient experience Virginia Mason and CHI Franciscan Health came together as natural partners to build a new health system centered around the patient: Virginia Mason Franciscan Health. Our combined system builds upon the scale and expertise of our nearly 300 sites of care including 11 hospitals and nearly 5000 physicians and providers. Together we are empowered to make an even greater impact on the health and well-being of our communities.

This job is responsible for working with members, providers and multi-disciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high need potential. Work is conducted in accordance with professional clinical standards and applicable accreditation/regulatory requirements. An incumbent maintains an ongoing member caseload for regular management and outreach, and work is strongly focused on ensuring that members are on track to progress towards desired outcomes based on quality care that is medically-appropriate and cost-effective based on the severity of illness and the site of service.
Care coordination is provided primarily through telephonic communication, home visits and/or direct face-to-face contact, and an incumbent uses motivational interview and clinical guideposts to educate, motivate and support change during member contacts. Local travel (up to 40%) may be required, depending on the complexity level of assigned member cases.

Work also includes: 1) completing clinical assessments and determining qualification for case management services; 2) developing, implementing, modifying and monitoring a case management plan to address member needs and goals; 3) documenting services provided in accordance with established guidelines; and 4) coordinating integrated outpatient care, including assessing barriers to care and identifying community resources and specific wellness programs (e.g. asthma, depression disease management) appropriate to enhance the continuity of care for members.

Work requires understanding of psychosocial and clinical education concepts, professional standards and accepted guidelines for patient care, community resources and applicable regulatory requirements. Knowledge of transitional case management concepts, methodologies and tools is also required. An incumbent uses the plan of care in giving members the tools they need to assist them in taking charge of their medical/psychosocial conditions to improve their overall health and quality of life, and to decrease the potential for hospital admissions/readmissions.

Education/Work Experience Requirements:

• Bachelor’s degree in social work, psychology, geriatrics, nursing, behavioral health or related field and one year of related work experience that would demonstrate attainment of the requisite job knowledge/abilities. Work experience in case management, social work or discharge planning is preferred.
• An equivalent combination of post-secondary education and work experience that would demonstrate attainment of the requisite job knowledge/abilities may be substituted for the degree requirement.

Licensure/Certification:

• Eligible for Agency Affiliated Counselor prior to date of hire and credential obtained within 60 days of hire.
• Current healthcare provider BLS certification.