Care Coach (Transition/Custodial Prevention)

The Care Coach assesses and evaluates member needs and requirements to achieve optimal wellness by guiding members and families toward appropriate resources. Responsibilities include providing specialized support for members receiving Long Term Services and Support (LTSS), focusing on health-related social needs, psychosocial support, and ensuring LTSS meets member needs. The role involves supporting members in Nursing Facilities (NF) by building relationships with staff, advocating for member care, and assessing their ability to return to the community. The Care Coach will contact members telephonically and face-to-face to establish goals, evaluate resources, develop care plans, and identify LTSS providers and community partnerships. They will focus on supporting members and/or caregivers through an interdisciplinary approach to access long-term services, social, housing, educational, and other services. Developing and modifying Individual Service Plans, involving the care team, and supporting members through navigation of LTSS and related needs are key duties. The Care Coach will make recommendations for Home and Community-Based Services (HCBS) to enable independence, facilitate interactions with payer sources, providers, and care teams, and educate members on maintaining Medicaid eligibility. Assisting with the entry of annual Level of Care assessments into the state portal is also a responsibility.