Overview

CareConnectMD DCE is a specialized High Needs Direct Contracting Entity (DCE) geared towards medically complex Medicare beneficiaries who reside in nursing homes, assisted living facilities, board and care facilities and at home. The comprehensive program provides a care model that is designed to meet the unique health care needs of medically complex Medicare beneficiaries. Under this value-based care model, CareConnectMD DCE will deliver care coordination services in close collaboration with primary care physicians, specialists, and advanced practice professionals in California, Georgia, Ohio, Indiana, Texas, as well as other expansion locations.

Learn more at www.careconnectmd.com

• Ensures that patients are care managed according to CareConnectMD mission, vision and values.
• This position is responsible for the assessment, care planning and coordination of care and evaluation of services for Medicare Beneficiaries aligned with the High Needs ACO with CareConnectMD.
• Patient’s wishes are aligned and known to team. Participate in goals of care discussion.
• Maintains and follows a panel of patients, ensuring patients’ needs are addressed in collaboration with the primary care clinician team. This includes patients residing long term in skilled nursing facilities, board and care, assisted living facilities as well as home.
• Monitor patients when they are transferred to an acute setting (ED, hospital, LTAC), obtaining updates on patients for Clinical Team, facilitating transition of care and continuing to follow patient in the post-acute setting.
• Serves as the primary point of contact for care coordination throughout the treatment episode at all levels of care.
• Coordinates and communicates with the interdisciplinary team to effectively manage care plans and transition of care settings. Communicates regularly with patient’s primary care provider and other clinicians.
• Collaborates and communicates with family members to optimize outcomes.
• Participates in multidisciplinary meetings, respecting and promoting patient choice and documents informed decision making.
• Maintains timely, complete, and accurate documentation in compliance with regulatory policies and procedures.
• Collaborates with nursing facility staff to ensure that patient is receiving care that is appropriate and consistent with medical necessity.
• Reviews and monitor patients’ utilization of skilled Part A and Part B services in nursing facility to include documentation of medical necessity and continued stay review.
• Acts as an effective liaison to facilities (hospital, skilled nursing, assisted living, memory care, and mental health) to ensure continuity and congruity of services in accordance with the patient’s Plan of Care.
• When on-site meets with patient and family to address needs.

• At least 2 years of experience in case management
• Experience in working in a long-term care setting preferred
• Experience in working with frail, medically complex patients
• Experience with Microsoft 365 (Microsoft word, excel, power point, Teams meetings, calendaring)
• Experience working with electronic medical records

• Ability to solve practical problems and deal with a variety of concrete variables in situations.
• Works independently, set priorities and handle multiple tasks with a high level of efficiency.
• Creative, flexible, well organized, resourceful, and detail-oriented
• Ability to handle confidential and sensitive information
• Excellent communication and interpersonal skills with the ability to effectively communicate with all levels of management, patients, and family members, various healthcare settings including clinic, hospitals, skilled nursing facilities for example
• Establishing and maintaining cooperative working relationships with others
• Excellent composition, grammar, and business language skills
• Work across different locations and time zones

• Licensed Nurse (LVN or RN)
• Current/Valid state driver’s license and insurance
• Must be a licensed driver with an automobile that is insured in accordance with state or organization requirements and is in good working order.

• Instills trust
• Customer focus
• Manages ambiguity
• Collaborates
• Drives results