University of Minnesota Physicians (M Physicians)
M Physicians is a non-profit organization actively seeking individuals in both clinical and non-clinical areas to contribute to the transformation of health and medicine. Headquartered in Minneapolis, our organization boasts a team of over 1,200 physicians, 300 advanced practice providers, and 2,200 health professionals and staff across Minnesota and beyond.
Join us on a mission to advance medicine.
Primary Job Objective:
Provides specialized geriatric case management and coordination of care for defined enrollees within designated managed care organizations. Conducts health risk assessments and manages utilization of services to achieve the most cost-effective manner to meet the client’s needs. Executes the delegation agreement between the Managed Care Organization (payer) and the health system while ensuring that all CMS & State regulatory requirements are met.
MSHO Care Coordinator LSW – Overview
Key responsibilities include but are not limited to:
- Carries a client caseload, completes MNChoice Assessments in the community, develops individualized Support Plans, and assists in preventing unnecessary hospital and nursing home admissions, allowing the member to remain in their community with all the necessary supports available.
- Responsible for delivery of MSHO care management as delegated through contracts by CMS, DHS, and health plans.
- Utilizing MNChoice platform to conduct comprehensive Assessment/Health Risk Assessment with our members in their homes to develop a Support Plan with a Person Centered and Informed Choice focus to maximize the level of self-determination and member choice of services.
- Incorporate an interdisciplinary/holistic and preventive focus to address concerns and determine actual or potential health concerns.
- Must be able to work with ethnically diverse populations and advocate on behalf of each member providing culturally appropriate care.
- Communicate with all identified parties of the Interdisciplinary Care Team as required.
- Must be able to meet DHS requirements for Certified Assessor training and certification.
2. Evaluates, documents, and monitors member’s health and wellbeing through change of condition and interim assessments, phone calls, throughout the continuum of care.
Identifies ongoing physical and mental health and safety needs to maintain optimal wellbeing in the least restrictive environment. Updates Support Plans based on the change of condition and/or interim assessments maximizing the level of self-determination and member choice of services, service providers, and living arrangements to meet member’s identified needs at that time. Identifies formal, quasi-formal, and informal support services to meet assessed needs. Facilitates timely referrals to Managed Care Specialists to identify service providers, initiate services, and process authorizations. Provides education, counseling, and general health information to members and member’s representatives. Knowledgeable in dealing with emergent situations as well as chronic disease processes and member needs throughout the continuum of care Maintains electronic records of all assessments, documents, and interactions regarding each member. Working knowledge of electronic medical record (EPIC) for each clinic.
3. Executes the delegation agreement between the Managed Care Organization and the health system and ensures all CMS & State regulatory and MCO requirements are met.
Knowledge and ability to cohere to the regulations as they pertain to the Managed Care Organizations and their delegation agreement. Identifies areas of growth and needs and shares with management to implement improvements within policies and procedures.
4. Assists in the education and development of family medicine clinics and residents.
Accompany residents (MD’s) to home assessment visit or visit within the clinic. Maintain regular communication with Primary Care Physicians and Interdisciplinary Care Team members as required by DHS/MCO’s. Attend meetings as mandated or requested.
5. Performs other duties including Performance Goals developed by manager and employee and reported in the employee’s Performance Review as part of UMPhysicians’ Performance Management tools
Maintains core/universal competencies and completes any new required learnings. Demonstrates all critical competencies and new required learnings.
Minimum Qualifications:
- Licensed SW in the state of Minnesota.
- MNChoice Certified Assessor highly preferred.
- Minimum of 1 year home and community-based service experience.
- 1-2 years geriatric case management.
- Previous MSHO/MSC+ care coordination experience highly preferred.
- Strong computer skills in Microsoft Word, Excel, Access, and Outlook.
- Reliable Transportation for home visits.
- Home Internet hook-up for a laptop.
- Experience with the use of MNChoice assessment platform highly preferred.
Hours: 1.0 FTE
M Physicians offers competitive salary and excellent benefits and provides you with the opportunity to enhance your career in the exciting field of health care through rewarding and challenging assignments and the opportunities for advancement.
We are an equal opportunity employer and value diversity at our company. We do not discriminate on the basis of race, religion, color, national origin, sex, gender, gender expression, sexual orientation, age, marital status, veteran status, or disability status. We will ensure that individuals with disabilities are provided reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.
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