Job Description
About Us:
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Astiva Health, Inc., located in Orange, CA is a premier healthcare provider specializing in Medicare and HMO services. With a focus on delivering comprehensive care tailored to the needs of our diverse community, we prioritize accessibility, affordability, and quality in all aspects of our services. Join us in our mission to transform healthcare delivery and make a meaningful difference in the lives of our members.
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SUMMARY: The Case Management Coordinator is responsible for gathering all relevant information for the identified member population during assessment, care planning, interdisciplinary care team meetings, and transitions of care. The Coordination performs troubleshooting when problem situations arise and takes independent action to resolve complex care issues.
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ESSENTIAL DUTIES AND RESPONSIBILITIES include the following:
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- Coordinate and assist with member appointments, transportation, and connection to community-based resources.
- Screen for and address social determinants of health (SDOH), including food insecurity, housing instability, and transportation barriers, and refer members to appropriate community resources.
- Coordinate delivery of services to members and their families, caregivers, or authorized representatives.
- Deliver culturally and linguistically appropriate coordination, including use of interpreter services when needed.
- Support execution of the approved Model of Care (MOC), including timely completion of Health Risk Assessments (HRAs), Individualized Care Plans (ICPs), and Interdisciplinary Care Team (ICT) meetings in accordance with CMS requirements for Special Needs Plans.
- Gather relevant information for the C-SNP member population during assessment, care planning, ICT meetings, and transitions of care.
- Complete applicable member assessments within established timeliness standards.
- Collaborate with the assigned case manager to resolve barriers to care and actively problem-solve for members with complex needs.
- Coordinate with primary care and specialty providers to support the delivery of care to members.
- Utilize the Division of Financial Responsibility (DOFR) and delegation agreements to inform routing and coordination decisions.
- Ensure all documentation and communication is complete and updated with partners at the IPA or MSO level, and that clinical teams have the information needed to authorize member services.
- Review available community resources prior to requesting authorization for plan-covered services.
- Accurately enter confidential member data into the case management system to ensure timely care coordination and outreach.
- Support the Utilization Management department by documenting inpatient, home health, and skilled nursing facility admissions in the appropriate systems.
- Maintain compliance with HIPAA, CMS, and state regulatory requirements, including documentation timeliness standards applicable to the C-SNP population.
- Manage an assigned member panel and meet established productivity and quality metrics.
- Collaborate with department leadership to coordinate calendars for meetings and facilitate interdisciplinary team communications.
- Serve as a resource for providers, internal teams, and external partners regarding plan policies, benefits, and care coordination workflows.
- Maintain regular and consistent attendance.
- Perform other duties as assigned.
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QUALIFICATION REQUIREMENTS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily, including regular and consistent attendance. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
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EDUCATION and/or EXPERIENCE:
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- High School diploma or GED required.
- Minimum of 2 years of experience working in the healthcare industry.
- Minimum of 1 year of prior experience working, training, or education within a healthcare environment.
- Strong working knowledge of prior authorization, case management principals, and regulations governing Medi-Cal, Medicare, and other government and commercial healthcare programs.
- Working knowledge or medical terminology.
- Excellent written and verbal communication skills with the ability to build and foster strong interpersonal relationships.
- Bilingual in a second language preferred.
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BENEFITS:
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- 401(k)
- Dental Insurance
- Health Insurance
- Life Insurance
- Vision Insurance
- Paid Time Off
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LANGUAGE: Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals.Ability to write routine reports and correspondence. Ability to speak effectively before groups and customers or employees of the organization.
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MATHEMATICS: Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.
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REASONING ABILITY: Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram or schedule form.
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EEO/AFFIRMATIVE ACTION STATEMENT: It is the policy of Astiva Health to provide equal employment opportunities without regard to race, color, religion, sex, national origin, age, disability, marital status, veteran status, sexual orientation, genetic information or any other protected characteristic under applicable law.This policy relates to all phases of employment, including but not limited to recruiting, employment, placement, promotion, transfer, demotion, reduction of workforce and termination, rates of pay or other forms of compensation, selection for training, the use of all facilities, and participation in all company sponsored employee activities. Provisions in applicable laws providing for bona fide occupational qualifications, business necessity or age limitations will be adhered to by the organization where appropriate. Please refer to Standard Operating Procedure 100 for more information about the organization’s Affirmative Action/EEO statement.
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PHYSICAL DEMANDS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
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While performing the duties of this job, the employee is frequently required to sit and complete work while on a computer. The employee occasionally is required to stand, walk, use hands to finger, handle or feel, reach with hands and arms, stoop, kneel, crouch or crawl, climb or balance, talk and hear.
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While performing the duties of this job, the employee is occasionally required to lift or exert force up to 10 pounds.
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WORK ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
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The noise level in the work environment is usually moderate.