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Complex Care Coordinator II

Complex Care Coordinator II

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Job Description


Complex Care Coordinators provide primary care management to members who have complex medical and/or behavioral health needs and are considered part of the Vulnerable Subpopulation [including members with significant mental illness and members with waivers for intellectual disability (ID), developmental disability (IFDDS), and/or requiring day support (DS). The Care coordinators focus on high risk Medicaid and/or dual-eligible members (adults and children) who are at risk for higher utilization of services, readmissions, and/or transitions. This role is mostly telephonic, but may involve some face-to-face interactions with the member to provide the support needed for ongoing care coordination to enhance quality, improve member outcomes, and encourage appropriate utilization of health services.


Medical Management

Medical Management educates members and empowers them to become active participants in their coordinated health care plans.  This team of knowledgeable professionals in their field provide services to include Utilization Review, Medical Outreach, Case Management, Disease Management, Credentialing, Social Work as well as Grievance and Appeals




  • Provides primary care management of members who are part of the Vulnerable Subpopulation to include Serious Mental Illness, complex and chronic medical and/or behavioral health conditions, and those receiving the Day Support (DS) or Intellectual Disability (ID) or Individual and Family Developmental Disabilities Support (DD) waivers.
  • Conducts time-sensitive, telephonic initial comprehensive assessment of the member’s medical and behavioral health, psychosocial needs, functional status, social history, including health literacy status and deficits, and develops an individualized care plan (ICP) collaboratively with the member, family, caregiver, PCP, and participants of the member’s interdisciplinary care team (ICT).
  • Conducts triggering assessments and updates to the ICP with the member, family or caregiver, the PCP/provider, other health care providers, and the community to maximize health care responses, quality and cost-effective outcomes
  • Conducts annual reassessments with the member with an updated ICP and ICT
  • Conducts face-to-face assessments with the member when appropriate
  • Facilitates communication and coordination between members of the health care team
  • Provides mentoring and oversight to Complex Care Coordinator I staff in the performance of assessments and development of ICPs.
  • Educates the member, the family or caregiver, and members of the health care team about treatment options, community resources, insurance benefits, psychosocial concerns, care management , etc., so that timely and informed decisions can be made.
  • Collaborates with the member’s ID/DD/or DS case manager to ensure waiver services are in place and appropriate for the member as well as incorporating these elements into the ICP and having the case manager to serve on the member’s ICT
  • Assists the member and their family/caregiver in navigating the health care system
  • Encourages the member to be actively involved in the health care decision-making process
  • Empowers the member to problem solve by exploring options of care, when available, and alternative plans, when necessary, to achieve desired outcomes
  • Encourages the appropriate use of health care services and strives to improve the quality of care and maintain cost effectiveness on a case-by-case basis.
  • Performs secondary review of service requests for residential treatment, substance abuse day treatment, and intensive outpatient treatment.
  • Collaborates with UR nurse to manage length of stay based upon medical necessity, community supports, and member’s specific social situation.
  • Provides referrals for brief and immediate crisis intervention (i.e. Adult Protective Services).
  • Collaborates with the transition coordinator to ensure member’s needs are met when undergoing transitions
  • Provides referrals to health-related services such as disease management and health education
  • Assists members who are in crisis
  • Strives to promote member self-advocacy and self-determination
  • Acts as an advocate for a member’s health care needs
  • Participates in VPHP’s ongoing quality improvement process
  • Participates in continuing educational activities as appropriate
  • Participates in care management rounds/meetings
  • Practices in accordance with applicable local, state and federal laws which govern confidentiality and medical information privacy regulations (HIPAA)
  • Leads and conducts regular communications with the member’s chosen ICT
  • Provides oversight and maintenance of the member’s ICP
  • Other duties as assigned




  • Registered Nurse licensed in the Commonwealth of Virginia (Bachelor degree preferred), or;
  • Licensed Clinical Social Worker in the Commonwealth of Virginia.
  • Certified Case Manager preferred


  • Bilingual – English and Spanish Preferred
  • Excellent Patient care evaluation skills and the ability to communicate well (written and verbal) with all levels of management, medical staff and employees.
  • PC literate with working knowledge of Microsoft Office and various computer software programs
  • Working knowledge of resource options, and experience in making appropriate referrals
  • Strong decision making skills, ability to handle multiple priorities
  • Knowledge of case management fundamentals
  • Some local travel will be required 


  • Minimum of 2 years clinical experience working with the elderly, disabled, low income/disadvantaged, and/or vulnerable subpopulations
  • Experience in care management, assessment, long-term member/patient care management or community based resource delivery
  • Previous work experience with behavioral health populations is needed
  • Knowledge of community resources preferred.


  • Physical health sufficient to meet the ergonomic standards and demands of the position.



About Us

Virginia Premier is a managed care organization which began as a full-service Medicaid MCO in 1995. Partnered with VCU Medical Systems we strive to meet the needs of the underserved and vulnerable populations in Virginia by delivering quality driven, culturally sensitive and financially viable Medicare and Medicaid healthcare programs.  Headquartered in Richmond, VA we also have offices in Roanoke, Tidewater and Bristol with additional satellite locations allowing us to serve over 200,000 members across eighty counties throughout Virginia. 


We offer competitive salaries and a comprehensive benefits package to include excellent Medical, Dental and Vision Plans, Tuition Assistance, Infant-At-Work Program, Remote Work options and generous vacation and sick leave policies. Our culture supports an environment where employees can continuously learn and gain professional growth through various development programs, education, exciting projects and career mobility.  


Our mission is to inspire healthy living within the communities we serve!

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