Care Coordinator - Transition of Care - Gallup, NM

ATTENTION MILITARY AFFILIATED JOB SEEKERS, - Our organization works with partner companies to source qualified talent for their open roles. The following position is available to, Veterans, Transitioning Military, National Guard and Reserve Members, Military Spouses, Wounded Warriors, and their Caregivers. If you have the required skill set, education requirements, and experience, please click the submit button and follow the next steps. Unless specifically stated otherwise, this role is 'On-Site' at the location detailed in the job post.Coordinate and collaborate with Prison Facilities via in person. Knowledge of community resources that help support incarcerated population.Coordinates care of individual clients with application to identified populations using assessment, care planning, implementations, coordination, monitoring and evaluation for cost effective and quality outcomes. Duties are typically performed during face-to-face home visits. Promotes the appropriate use of clinical and financial resources in order to improve the quality of care and member satisfaction. Assists with orientation and mentoring of new team members as appropriate.Provides care coordination to members with behavioral health conditions identified and assessed as requiring intensive interventions and oversight including multiple, clinical, social and community resources.Conducts in depth health risk assessment and/or comprehensive needs assessment which includes, but is not limited to psycho-social, physical, medical, behavioral, environmental, and financial municates and develops the care plan and serves as point of contact to ensure services are rendered appropriately, (i.e. during transition to home care, back up plans, community based services).Implements, coordinates, and monitors strategies for members and families to improve health and quality of life outcomes.Develops, documents and implements plan which provides appropriate resources to address social, physical, mental, emotional, spiritual and supportive needs.Acts as an advocate for member`s care needs by identifying and addressing gaps in care.Performs ongoing monitoring of the plan of care to evaluate effectiveness., Measures the effectiveness of interventions as identified in the members care plan.Assesses and reviews plan of care regularly to identify gaps in care, trends to improve health and quality of life outcomes., Collects clinical path variance data that indicates potential areas for improvement of case and services provided., Works with members and the interdisciplinary care plan team to adjust plan of care, when necessary.Educates providers, supporting staff, members and families regarding care coordination role and health strategies with a focus on member-focused approach to care.Facilitates a team approach to the coordination and cost effective delivery to quality care and services., Facilitates a team approach, including the Interdisciplinary Care Plan team, to ensure appropriate interventions, cost effective delivery of quality care and services across the continuum.Collaborates with the interdisciplinary care plan team which may include member, caregivers, member`s legal representative, physician, care providers, and ancillary support services to address care issues, specific member needs and disease processes whether, medical, behavioral, social, community based or long term care services. Utilizes licensed care coordination staff as appropriate for complex cases.Provides assistance to members with questions and concerns regarding care, providers or delivery system.Maintains professional relationship with external stakeholders, such as inpatient, outpatient and community resources.Generates reports in accordance with care coordination goal.The job duties listed above are representative and not intended to be all-inclusive of what may be expected of an employee assigned to this job. A leader may assign additional or other duties which would align with the intent of this job, without revision to the job description.

Created: 2025-10-31