The Outpatient Care Coordinator II will identify and reduce barriers to members' care, assist the member in locating and accessing resources and educate the member on the importance of accessing care promptly. Serve as the primary point of contact with members and will be an integral part of the member's interdisciplinary care (ICT) team, provide support to the member as they self-navigate the health care system, and work closely with member's case management team to resolve access, medical and psychosocial related issues. Efficiently manage and prioritize assigned caseload while working with a licensed clinical professional (case manager) to ensure optimal coordination of care for the Health Plan members. This position will serve as a liaison between Health Plan members, Prospect, Primary Care Provider (PCP), specialists and other members of the health care team.With approximately 9,000 physicians to serve our 260,000 members, Prospect Medical Systems is proud to be among the most innovative medical systems in California, Texas and Rhode Island. Our extensive care services range from primary care and specialty physician services to acute care hospital and skilled nursing facilities to behavioral health and wellness services. Each of our Independent Physician Associations (IPAs) and networks support the use of advanced diagnostic and treatment tools to provide our members with convenient access to state-of-the-art healthcare. For 25+ years, Prospect Medical has been focused on our mission of supporting independent physicians where, through risk arrangements, we work closely together with health plans, facilities and healthcare physicians for the benefit of every person who comes to us for care. We provide quality healthcare services that are designed to offer our patients highly coordinated, personalized care and that help them live healthier lives. Prospect Medical Systems manages highly successful IPAs by leveraging our best-practices, results-driven administrative services to manage patients under risk arrangements with health plans/CMS.Minimum Education: High School Diploma required. Associates Degree or higher preferred.
Minimum Experience: Minimum of one (1) year of experience in Case Management Care Coordination in an HMO environment; or any combination of education and experience which would provide an equivalent background required. Prior experience with Managed Care organization preferred. Knowledge of managed care and healthcare preferred. Bilingual language proficiency preferred. Ability to prioritize and multi-task. Excellent communication skills. Working with the needs of seniors or persons with disabilities (SPD) in a customer/member service capacity, HMO, Medi-Cal and/or health services experience preferred. Maintain a professional attitude when working with internal and external customers.
Req. Certification/Licensure: Medical Assistant Certification preferred. Medical Terminology certificate preferred.
Conducts telephonic outreach to members to discuss and offer Outpatient clinical programs.
Oversee a caseload of basic members to manage and coordinate care according to members' identified needs.
Interact with assigned members telephonic and/or in-person as appropriate.
Review of Health Risk Assessment and identify member's coordination of care needs.
Established member-friendly care goals with members.
Coordinate care for members as appropriate such as scheduling appointments, creating authorizations to facilitate/expedite member's requests, etc.
Facilitates completion of quality measures through education and coordination.
Timely processing of incoming referrals to Outpatient programs per set timeframes.
Completes post-discharge calls for members per set timeframe. Determines additional post-discharge needs such as scheduling follow-up appointments, coordinating ordered DME and services, etc.
Collaborates with the health plan, PCP, and health care team to ensure timely coordination of member's needs.
Facilitates warm transfers to member's assigned case manager in accordance with member needs, when appropriate.
Completes post discharge calls for members per set timeframe. Determines additional post-discharge needs such as scheduling follow up appointments, coordinating ordered DME and services, etc.
Identifies the need for, and facilitates, referrals to Long Term Support Services (LTSS), Behavioral Health, and other community resources.
Guides members in understanding and accessing the health plan benefits they are entitled to.
Maintains timely documentation of member's case, care plan, interventions, and interdisciplinary care team within Prospect's care management system.
Mail out educational and community resources information to members.
Assist Case Managers in obtaining medical records for members.
Generate letters, faxing to PCP, and mailing to members along with resources.
Maintains compliance with established departmental productivity guidelines.
Maintain internal department trackers and reports.
Other projects and duties as assigned.
Conducts telephonic outreach to members to discuss and offer Outpatient clinical programs.
Oversee a caseload of basic members to manage and coordinate care according to members' identified needs.
Interact with assigned members telephonic and/or in-person as appropriate.
Review of Health Risk Assessment and identify member's coordination of care needs.
Established member-friendly care goals with members.
Coordinate care for members as appropriate such as scheduling appointments, creating authorizations to facilitate/expedite member's requests, etc.
Facilitates completion of quality measures through education and coordination.
Timely processing of incoming referrals to Outpatient programs per set timeframes.
Completes post-discharge calls for members per set timeframe. Determines additional post-discharge needs such as scheduling follow-up appointments, coordinating ordered DME and services, etc.
Collaborates with the health plan, PCP, and health care team to ensure timely coordination of member's needs.
Facilitates warm transfers to member's assigned case manager in accordance with member needs, when appropriate.
Completes post discharge calls for members per set timeframe. Determines additional post-discharge needs such as scheduling follow up appointments, coordinating ordered DME and services, etc.
Identifies the need for, and facilitates, referrals to Long Term Support Services (LTSS), Behavioral Health, and other community resources.
Guides members in understanding and accessing the health plan benefits they are entitled to.
Maintains timely documentation of member's case, care plan, interventions, and interdisciplinary care team within Prospect's care management system.
Mail out educational and community resources information to members.
Assist Case Managers in obtaining medical records for members.
Generate letters, faxing to PCP, and mailing to members along with resources.
Maintains compliance with established departmental productivity guidelines.
Maintain internal department trackers and reports.
