Job Title
Care Coordinator
Pay
$20-30 per hour
Employment
W-2
Employment Term
At-will
Position Summary
The Care Coordinator is responsible for the end-to-end management of clients enrolled in Divine Agape Health Care Agency's home care services. The Care Coordinator applies the same standards to every client on the caseload, regardless of payor, program, or referral source. The Care Coordinator serves as the primary point of contact for the client, the client's managed care plan or payor, caregivers, and inter-departmental teams — from the moment a referral is received, through the duration of active services, and through service closure when applicable. This role requires exceptional organizational skills, compassionate client communication, strict documentation discipline, and the ability to manage complex, time-sensitive processes across multiple systems and stakeholders simultaneously.
Essential Duties & Responsibilities
The following responsibilities are essential functions of this position. Additional duties may be assigned by the Care Coordinator Supervisor.
Referral Processing & Client Intake
• Receive, log, and process all incoming referrals in AlayaCare on the same business day of receipt, regardless of referral source.
• Conduct and document a 5-point duplicate check before creating any new client profile.
• Create and maintain accurate client profiles with status set to PENDING upon intake.
• Coordinate with the Care Coordinator Supervisor to ensure all referrals are assigned and acted upon within mandated SLA timelines.
• Attempt first client contact on the same business day a referral is assigned.
• Manage incomplete referrals by pursuing missing data from referring sources in parallel with other intake steps — never holding the intake process.
• Follow the 3-attempt outreach protocol for clients who cannot be reached, escalating to the supervisor after 3 failed attempts over 3 business days.
Client Profile & AlayaCare Documentation
• Maintain complete, current, and accurate client profiles in AlayaCare throughout the client's enrollment.
• Document all client interactions, contact attempts, status changes, and case milestones on the same business day they occur — no retroactive or batch documentation.
• Use the standardized note formats required by GUIDE-CC-030 for every documentation type.
• Update client status accurately and in real time: PENDING → WAITING LIST → ACTIVE → ON HOLD / CLOSED.
• Maintain all supporting documents per the currency requirements of GUIDE-CC-020 (no document older than 90 days submitted for authorization).
• Use Tasks V2 in AlayaCare as the single organizer for outstanding work; group the caseload by Zone A (Top Lane) / Zone B / Zone C per the CC zone model.
Assessment & Authorization Submission
• Conduct the initial client assessment in-person — this is mandatory for every initial assessment regardless of payor or program.
• Conduct reassessments using the client's preferred modality (phone, video, or in-person) per SOP-CC-006.
• Complete the required functional assessment form with the client within 3 hours of first successful contact.
• Upload all required supporting documents to the payor/MCP portal using the naming conventions in GUIDE-CC-006.
• Submit authorization requests to the payor within 3 hours of client contact, following SOP-CC-022 and SOP-CC-003.
• Update AlayaCare status to WAITING LIST and build the client's recurring service schedule after successful submission.
• Navigate IHSS overlap scenarios using GUIDE-CC-002 (IHSS Decision Tree) when calculating net-authorized service hours.
• When a client has sufficient IHSS hours but no stable provider, authorize 1–2 months only until the provider stabilizes; document the reasoning in AlayaCare.
Authorization Monitoring & Payor Coordination
• Monitor all open authorization statuses using the Data Explorer authorization-expiration report and the Top Lane Outstanding List.
• Submit reauthorization packages to the payor at least 30 calendar days before authorization expiration.
• Request bridge authorization at 14 days remaining if reauth has been submitted but not yet approved.
• Communicate with the payor's care management team to resolve authorization inquiries, documentation requests, and portal issues.
• Escalate authorization denials, expirations, and delays to the CC Supervisor immediately.
Service Initiation & Scheduling Coordination
• Upon authorization approval, notify the client within 1 business day and submit a service initiation request to Scheduling within 24 hours.
• Coordinate with the Scheduling Department to ensure caregiver placement within 5 business days of authorization approval.
• Introduce the assigned caregiver to the client by phone before the first service visit.
• Verify first visit occurrence within 1 business day of the scheduled start date.
• Report any scheduling failures, caregiver no-shows, or service disruptions per SOP-CC-020.
Continuous Client Monitoring & Service Oversight
• Conduct scheduled client check-ins (at minimum monthly for active clients; weekly for RED-flag clients) to monitor satisfaction, functional status, safety, and service adequacy.
• Identify changes in client needs and coordinate care plan adjustments with the CC Supervisor.
• Monitor service utilization to prevent under-delivery or over-delivery relative to authorized hours.
• Identify and address service gaps or disruptions proactively and in compliance with SOP-CC-005.
• Reassess clients per SOP-CC-006 as scheduled or when significant changes in need occur.
Risk, Safety & Mandatory Reporting
• Identify and respond to client safety concerns and risk flags per SOP-CC-016 and GUIDE-CC-008.
• File mandatory abuse, neglect, and exploitation reports with APS or the appropriate agency per California Welfare & Institutions Code §15630 (SOP-CC-017).
• Follow post-reporting protocol per SOP-CC-025, including supervisor notification, payor notification, service continuation decisions, and APS coordination.
• Apply enhanced monitoring (minimum weekly contact) for all clients with open APS investigations.
• Report incidents, grievances, and complaints per SOP-CC-007 on the same day the event is identified.
Hospitalization, Institutionalization & Status Changes
• Follow SOP-CC-019 when a client is hospitalized or admitted to a facility — update status to ON HOLD, document clearly, and notify the payor within 24 hours.
• Coordinate service resumption with Scheduling upon confirmed client discharge to home.
• Manage client disengagement and refusal of services per SOP-CC-021.
• Process all service closures and discharges per SOP-CC-009, with CC Supervisor authorization.
Inter-Department Coordination & Compliance
• Coordinate with the Scheduling Department for service initiation requests, caregiver changes, and schedule modifications per GUIDE-CCS-004.
• Provide Billing with timely notification of authorization approvals, changes, expirations, and service closures.
• Refer QA and compliance matters to the CC Supervisor as appropriate.
• Adhere to all agency SOPs, payor contract requirements, and applicable program rules at all times — applied identically across every client.
• Complete all required trainings (mandatory reporting, HIPAA, program-specific) within designated deadlines.
• Document all PHI exclusively within HIPAA-compliant systems (AlayaCare, payor/MCP portals) — no PHI via personal email or text.
• Maintain role boundaries as defined in SOP-CC-010, escalating any tasks outside the CC's scope of authority.
Working Conditions & Physical Requirements
• Primary work environment: office-based with possible hybrid/remote work arrangements as approved.
• Regular use of computer, phone, and electronic health record systems throughout the work day.
• Required to conduct in-person client visits for initial assessments; occasional in-person visits for field follow-ups.
• Occasional exposure to emotionally sensitive content when working with vulnerable adult clients.
• Ability to sit and use computer equipment for extended periods; ability to drive to client homes.
• Must manage concurrent tasks and meet time-sensitive deadlines in a fast-paced environment.
Additional Requirements
• Must maintain strict HIPAA compliance and client confidentiality at all times.
• Must complete all required agency and program-specific training within established deadlines.
• Subject to background check and references as a condition of employment.
• Must possess a valid driver's license and maintain personal automobile liability insurance.
• Required to read, sign, and adhere to all DAHCA Care Coordinator SOPs, Guides, and Policies upon hire and upon any updates.
Working Conditions & Physical Requirements
• Primary work environment: office-based with possible hybrid/remote work arrangements as approved.
• Regular use of computer, phone, and electronic health record systems throughout the work day.
• Required to conduct in-person client visits for initial assessments; occasional in-person visits for field follow-ups.
• Occasional exposure to emotionally sensitive content when working with vulnerable adult clients.
• Ability to sit and use computer equipment for extended periods; ability to drive to client homes.
• Must manage concurrent tasks and meet time-sensitive deadlines in a fast-paced environment.