*Position will work in the remote & in the field in Riverside, CA & the surrounding areas*
Enhance frail seniors' ability to age in place, manage their health, navigate the health care system, and live independently by providing person-centered care in accordance with ECM requirements. This individual will act as an integral part of the care team by working directly with members telephonically and in-person to implement plans of care, advocate on behalf of the member and provide member-centric interventions.
- Collaborate in conducting the most comprehensive assessments to identify chronic conditions and psychosocial challenges affecting independent living. Perform assessments for Medi-Cal/Medicare dual-eligible members referred to Complex Care Management.
- Support member well-being through observation, positive communication, and motivational interviewing. Conduct face-to-face or phone visits to address care barriers, ensure engagement in primary and preventative care, and support individualized care plan implementation.
- Provides specialized care coordination utilizing an advanced level of understanding and empower members and their families in managing chronic conditions through coaching, education, healthcare navigation, advocacy, accompaniment to appointments and referrals to community, county, and state resources.
- Implement personalized care plans tailored to the medical and social needs of high-risk members, incorporating realistic health goals supporting members inherent wishes.
- Actively participates in interdisciplinary planning and case conference meetings to ensure person-centered care and to ensure member receives support following discharge from an inpatient or institutional setting.
- Demonstrates high-level organizational, follow-through, and engagement skills to achieve positive member outcomes. Adheres to SNP policies and ensures timely, accurate documentation of care plans, service plans, and progress notes within established timeframes.
- Network and build relationships with community business organizations like senior and wellness centers, housing outreach events, shelters, landlords, legal aid providers, etc.
- Utilizes department desktop procedures, workflows, job aids and training material. Identifies barriers to work processes and brings to the attention of the supervisor/manager.
- Performs work under minimal supervision. Handles complex issues and problems and refers only the most complex issues to higher-level staff. Possesses comprehensive knowledge of subject matter.
- We seek Rebels who are curious about AI and its power to transform how we operate and serve our members.
- Actively support the achievement of SCAN’s Vision and Goals.
- BILINGUAL required in English/Spanish. (Test will be administered to assess proficiency if applicable.)
- Travel 50+% of the time in the assigned area- Must have a valid driver’s license, automobile insurance and reliable transportation.
- 5+ years managed care, healthcare environment, lived experience or case management.
- 2+ years working with seniors, conducting home visits, and working remotely strongly preferred.
- Technical expertise - Advanced technical skills for functional area
- Communication - Good communication and interpersonal skills
- Strong interpersonal skills, including excellent written and verbal communication skills.
- Ability to collaborate effectively within a multidisciplinary team.
- General understanding of NCQA standards, CMS and DHCS regulations.
- General knowledge of medical terminology and abbreviations.
- Deep understanding of local community resources for seniors.
To ensure the health and safety of our members, if you are selected for this position, your job offer with SCAN will be contingent on providing proof of Tuberculosis screening upon hire or providing proof of a negative screening within the last year. If you have a disability/medical reason or sincerely held religious belief that prevents you to provide information required in this policy, SCAN will initiate and engage in the interactive process to evaluate what, if any, reasonable accommodations may be available.
- Eleven paid holidays per year, plus 1 floating holiday, plus 1 birthday holiday
- Excellent 401(k) Retirement Saving Plan with employer match and contribution