This position is responsible for implementing a care management program that focuses on improving the health status of PrimeWest Health members, both individually and as a community, while reducing health care costs. The Special Needs Plan Care Coordinator will achieve this through following Centers for Medicare & Medicaid Services (CMS) rules/regulations related to Special Needs Plans (SNPs) and facilitating the coordinated and integrated delivery of health and wellness services provided to PrimeWest Health members by PrimeWest Health’s contracted health care and human services providers. The Special Needs Plan Care Coordinator is responsible for providing a coordinated care continuum for members enrolled in PrimeWest Health’s Special Needs BasicCare (SNBC), Minnesota Senior Care Plus (MSC ), Prime Health Complete (HMO SNP), and PrimeWest Senior Health Complete (HMO SNP) programs. This position is also responsible for fostering collaborative relationships with county partners and providers and collaborating with county case managers and other PrimeWest Health care coordinators to improve care throughout the continuum of health care services.
A. Reporting Accountability
This position is responsible for meeting the following regulatory, contractual, or other requirements on behalf of PrimeWest Health:
1. Knowledge of Minnesota Department of Human Services (DHS), CMS, and National Committee for Quality Assurance (NCQA) requirements
B. Role and Key Responsibilities Assist the Special Needs Plan Manager, PrimeWest Health staff, and county agencies in the following as needed:
1. Assess the individual and aggregate health status of members
2. Coordinate care for PrimeWest Health members through collaboration with all providers across all settings
3. Facilitate access to specialists and therapies in coordination with Utilization Management staff and members’ assigned county case managers
4. With an interdisciplinary care team, coordinate person-centered member care plans to ensure the appropriateness, quality, and cost effectiveness of services provided to members
5. Monitor effectiveness of care management and care coordination plans
6. Collaborate with county agencies in achieving community health improvement
7. Assist in fully implementing the PrimeWest Health care management model
8. Participate in and conduct care management educational trainings as needed, including training on the PrimeWest Health care management model and expected outcomes
9. Update assessment tools, resources, and workflows as assigned
10. Collaborate with all efforts to comply with and improve outcomes for Performance Improvement Projects (PIPs) and Healthcare Effectiveness Data and Information Set (HEDIS®) measures
11. Assist in developing and implementing continuous care coordination and quality improvement plans
12. Conduct monthly monitoring with follow-up regarding utilization management pertinent to area of assigned responsibility
13. Monitor members’ transitions of care from one setting to another
14. Participate in committees as assigned
15. Participate in Interdisciplinary Care Team (ICT) meetings as appropriate
PrimeWest Health is an Equal Opportunity Employer Committed to Diversity, Equity, and Inclusion
Position Description: Special Needs Plan Care Coordinator Page 2 of 2
16. Participate actively in new initiatives as assigned
17. Participate actively in county case manager trainings
18. Participate actively in monthly county supervisor meetings
19. Implement the four dimensions of optimal member health and well-being (4D): improving members’ health care experience (care outcomes, care quality, member satisfaction); improving member population health; achieving health equity across our entire member population; and improving the value of health care provided to members in day-to-day care coordination tasks
C. General PrimeWest Health Responsibilities
1. Abide by the PrimeWest Health Code of Conduct
2. Comply with all PrimeWest Health policies and procedures
3. Comply with the Health Insurance Portability and Accountability Act (HIPAA) and all other privacy laws
4. Be familiar with building safety procedures and alert maintenance if something requires attention
5. Keep public areas of the department and office neat and clean
6. Conduct other responsibilities and activities as needed and assigned
D. Professional Competencies
1. Produce accurate and high-quality work
2. Demonstrate excellent organizational and time management skills and the ability to work effectively with minimal supervision and structure
3. Demonstrate practical knowledge of clinical standards and outcomes (e.g., HEDIS measures and NCQA requirements)
E. Educational Requirements and Required Qualifications
1. Graduate of approved school of nursing with BS/MS preferred and expertise in assigned area of responsibility.
2. Demonstrated knowledge of, and proficiency in, Word, Excel, and Outlook required. Experience in working with electronic care management documentation systems is a plus. Use of standard office equipment required.
3. Flexibility and ability to handle multiple tasks. Ability to work effectively with a variety of people both within and outside of the organization. Excellent verbal and written communication skills as well as strong interpersonal skills.
4. Ability to sit at a desk or computer station most of the time. Ability to occasionally lift and/or carry such articles as file folders and small boxes up to 20 pounds. Some travel required, possibly overnight.
F. Appropriate Licensure and Certification Requirements
1. Must possess current and unrestricted registered nurse (RN) license in the State of Minnesota
2. Must attend continuing education sessions each year to support license requirement
G. Collaborative Efforts with Other Departments
1. Administrative Services
2. Corporate Compliance & Auditing
3. Business IT & Claims Administration
4. Information Systems & Technology
5. Member & Provider Services
6. Operations
7. Quality & Utilization Management
8. Pharmacy Management
H. Supervision – N/A
This position description is not to be construed as an exhaustive statement of essential functions or responsibilities.
Alexandria, Minnesota – This position offers the possibility for remote or hybrid work
PrimeWest Health will accept résumés for this position until filled. No phone inquiries please. Employment to begin as soon as possible.