Social Support Complex Care Coordinator-2

We’re unique. You should be, too. We’re changing lives every day. For both our patients and our team members. Are you innovative and entrepreneurial minded? Is your work ethic and ambition off the charts? Do you inspire others with your kindness and joy? We’re different than most primary care providers. We’re rapidly expanding and we need great people to join our team. The Social Support Complex Care Coordinator (SSCCC) serves as the central hub for managing PCP referrals related to social support, acute patient needs, and behavioral health concerns — connecting patients to the right in-house care teams, community resources, and payer-supported programs before unmet needs escalate into medical crises. This role takes full ownership of the social support complex care continuum from referral intake through resolution. By proactively identifying and addressing social determinants of health (SDOH) and behavioral health needs, the SSCCC is instrumental in reducing hospitalizations, simplifying complex care, lowering the total cost of care, and delivering on ChenMed's promise of love, dignity, and exceptional service to the seniors we serve. ESSENTIAL JOB DUTIES/RESPONSIBILITIES: Referral Management and Care Coordination Responds directly to the referral question, provides effective and timely feedback to the PCP, and proactively follows up with providers when clinically indicated, including in response to medication side effects or alarming medical or psychiatric symptoms. Maintains consistent focus on recommendations that reduce Emergency Department utilization. Receives, reviews, triages, and manages PCP referrals for social support, SDOH, and behavioral health needs within 24 hours of receipt Identifies and escalates patients at imminent risk of hospitalization or emergency department visits Routes referrals to appropriate in-house care teams, including SDOH teams, local market nursing, behavioral health and care management, and community social workers Conducts initial screening and brief functional assessments to determine appropriate level of care and urgency Collaborates with clinical staff in the development and execution of care plans that address both clinical and social needs, and report care plan variations to the PCP with appropriate follow-through Monitors referral outcomes, follow up to ensure timely, full circle care delivery, and maintain accurate documentation in the EHR within required timelines Participates in care team huddles, case conferences, and multidisciplinary meetings via remote platforms Serves as a patient advocate, ensuring complex and high-risk patients receive coordinated, compassionate, and culturally sensitive care Appropriately assigns patients to specialty behavioral health services when indicated Supports PCPs by delivering brief, targeted assessment, consultation, intervention, and triage for patients screening positive for behavioral health concerns Facilitates linkages to specialty behavioral health treatments, including psychiatric evaluation, psychotherapy, addiction recovery, and crisis stabilization services Applies evidence-based assessment tools and protocols in support of PCP-led care Monitors clinical progression, relapses, service utilization, and associated costs for patients with behavioral health diagnoses Reports observed or suspected child or adult abuse pursuant to mandated reporting requirements Identifies and assesses patients' social needs, including food insecurity, housing instability, transportation barriers, financial hardship, social isolation, utility access, and aging in place supports Identifies, engages, and utilizes community resources to stabilize social needs and prevent care disruptions. Tracks, documents, and reports SDOH interventions and outcomes for quality improvement and compliance purposes. Collaborates closely with Community Nurse Case Managers, Market Medical Directors, and behavioral health and community service vendors to coordinate and monitor the quality, frequency, and appropriateness of outpatient visits and community-based services. Facilitates outpatient referrals to preferred providers as appropriate and assists patients and families with access to community and financial resources. Works with market leaders to identify trends in social support needs and recommend process improvements. Helps patients navigate the behavioral health care system by connecting them with community resources, coordinating multiple facets of care delivery, and assisting with administrative and logistical tasks. Maintains strict confidentiality of patient and agency matters at all times. Completes documentation in a timely manner to support effective care coordination. Other duties as assigned and modified at manager's discretion. KNOWLEDGE, SKILLS AND ABILITIES: Demonstrates effective time management, rapid problem identification, and appropriate use of evidence-based assessment tools. Possesses basic knowledge of psychotropic medications Demonstrate working knowledge of Medicare Advantage, Medicaid, and commercial insurance payer systems, including plan benefits, care management programs, eligibility and enrollment, Medicare Savings Programs (MSPs), Low Income Subsidy (LIS/Extra Help), prior authorization processes, Non-Emergency Medical Transportation (NEMT) benefits, and Medicare Advantage supplemental benefits Ability to learn insurance payer systems across multiple states Demonstrated understanding and utilization of management principles in an HMO model and Medicare and Medicaid payment methodologies to inform care coordination decisions Strong listening skills and uses evidence-based interviewing strategies to engage patients in constructive dialogue. Writes clear, concise medical record notes that are consistent with verbal and written feedback provided to the PCP. Ability to apply culturally relevant and appropriate approaches with people of diverse cultural, socioeconomic and educational backgrounds. Flexibility in schedule. Knowledge of MS Office Suite. Ability to prioritize and multi-task. Demonstrated openness to feedback. Maintains professionalism in all care settings. Spoken and written fluency in English This job requires use and exercise of independent judgment Remote Work Requirements The Social Support Complex Care Coordinator must maintain a dedicated, private, and HIPAA-compliant home workspace with reliable high-speed internet access. The incumbent must demonstrate proficiency with approved remote communication and collaboration platforms, maintain consistent availability during scheduled work hours, and adhere to all ChenMed remote work, security, and compliance policies. EDUCATION AND EXPERIENCE CRITERIA: Bachelor’s degree in healthcare related field OR additional experience above the minimum will be considered in lieu of the required education on a year-for-year basis required Minimum of two (2) years’ experience in behavioral health case management. Certification in case management. Working knowledge of evidence-based interventions and behavioral medicine requirements. Working knowledge of local behavioral health providers and services, policies and payment mechanisms. Primary care or behavioral health/primary care integration experience a plus. PAY RANGE: $49,871 - $71,243 Salary The posted pay range represents the base hourly rate or base annual full-time salary for this position. Final compensation will depend on a variety of factors including but not limited to experience, education, geographic location, and other relevant factors. This position may also be eligible for a bonuses or commissions. EMPLOYEE BENEFITS We’re ChenMed and we’re transforming healthcare for seniors and changing America’s healthcare for the better. Family-owned and physician-led, our unique approach allows us to improve the health and well-being of the populations we serve. We’re growing rapidly as we seek to rescue more and more seniors from inadequate health care. ChenMed is changing lives for the people we serve and the people we hire. With great compensation, comprehensive benefits, career development and advancement opportunities and so much more, our employees enjoy great work-life balance and opportunities to grow. Join our team who make a difference in people’s lives every single day. Current employees, if you want to apply to our internal career site, please click HERE Current Contingent Worker please see job aid HERE to apply #LI-Hybrid