Introduction 

Care coordination services are essential in managing the healthcare needs of individuals with complex or chronic conditions. Care coordinators help patients navigate medical, social, and community-based services, ensuring continuity of care and improving health outcomes. Starting a care coordination agency may require that your staff hold specific licensure, such as social work or nursing licensure, depending on the type of services you provide and your state's regulatory requirements. 

This guide outlines the steps to starting a care coordination agency, including required licensure, certifications, and best practices for maintaining compliance and delivering high-quality, patient-centered services. 

Step-by-Step Guide to Starting a Care Coordination Agency 

1. Determine the Type of Care Coordination Services You Will Offer 

Care coordination services can range from basic patient support, such as appointment scheduling and medication management, to more comprehensive care, including case management, care planning, and referrals to social and community services. The scope of your services will influence the licensure requirements for your staff. 

Action Point: Define the services your agency will provide. Common care coordination services include managing healthcare appointments, assisting with medication adherence, providing referrals to specialists or community resources, and helping patients manage chronic conditions. 

Tip: If your care coordination services include behavioral health support or clinical care management, you may need staff with advanced degrees and licensure in fields such as nursing, social work, or psychology. 

2. Understand Licensing Requirements for Care Coordinators 

Many states require that care coordinators hold specific licensure, such as a social work or nursing license, particularly if the services provided include clinical care, behavioral health, or case management. For example, care coordinators who manage complex medical care may need to be registered nurses (RNs), while those providing social services may need to be licensed social workers (LSWs). 

Action Point: Check with your state’s Department of Health, Department of Social Services, or Department of Nursing to identify the licensure requirements for care coordinators in your state. Determine whether your staff will need a Licensed Clinical Social Worker (LCSW), Registered Nurse (RN), or Certified Case Manager (CCM) credential. 

Tip: If you are unsure about the level of licensure required, consult with a healthcare attorney or professional licensing board to ensure your agency remains compliant with state regulations. 

3. Hire Qualified Care Coordinators with the Appropriate Licensure 

Based on the services you plan to offer and your state's requirements, you will need to hire care coordinators with the appropriate qualifications and licensure. Common roles in care coordination include nurses, licensed social workers, and certified case managers. 

Action Point: Recruit care coordinators with the necessary credentials. For medically-focused care coordination, look for RNs or Licensed Practical Nurses (LPNs). For social services coordination, hire LSWs or Licensed Master Social Workers (LMSWs). For complex case management, consider hiring individuals with a Certified Case Manager (CCM) or Care Manager Certified (CMC) designation. 

Tip: Ensure your staff receives continuing education to maintain their licensure and stay up to date with best practices in care coordination, case management, and patient advocacy. 

4. Ensure Your Care Coordinators Meet Certification Requirements 

In addition to licensure, many care coordinators pursue certifications that demonstrate expertise in managing patient care across various settings. Certifications such as Certified Case Manager (CCM), Certified Professional in Healthcare Quality (CPHQ), or Care Manager Certified (CMC) are often preferred for care coordinators, particularly those handling complex patient cases. 

Action Point: Encourage staff to obtain certifications that align with their roles. For example, RNs in care coordination might pursue the Case Management Certification (CCM), while social workers could benefit from the Certified Social Work Case Manager (C-SWCM) credential. 

Tip: Certification may be required by insurance companies or government programs like Medicaid or Medicare for certain services, so ensure your staff’s certifications are compatible with payer requirements. 

5. Apply for Medicaid and Medicare Provider Enrollment 

If your agency plans to work with clients covered by Medicaid or Medicare, you will need to apply to become an approved provider. Both programs have strict eligibility and reporting requirements for care coordination services. 

Action Point: Submit applications to become a Medicaid and Medicare-approved provider through your state’s Medicaid office and the Centers for Medicare & Medicaid Services (CMS). Be prepared to provide documentation on your agency’s services, staff qualifications, and financial management practices. 

Tip: Familiarize yourself with the billing codes and documentation requirements for Medicaid and Medicare care coordination services. This will ensure timely and accurate reimbursement for services provided. 

6. Develop Care Coordination Protocols and Policies 

To ensure consistency and quality in your services, you must develop comprehensive care coordination protocols. These policies should include the steps your care coordinators will take to assess patient needs, coordinate services, communicate with healthcare providers, and monitor patient outcomes. 

Action Point: Create policies that outline the processes for client intake, assessment, care planning, service referrals, follow-up, and documentation. Ensure that all policies adhere to HIPAA (Health Insurance Portability and Accountability Act) standards for patient privacy. 

Tip: Involve your staff in the development of these protocols to ensure that they are practical, efficient, and reflective of the daily realities of care coordination. Regularly review and update protocols as care models evolve. 

7. Implement a Client Management and Reporting System 

Care coordination agencies must maintain detailed records of client interactions, care plans, and services provided. Implementing an electronic health record (EHR) or client management system will help your agency stay organized and meet the documentation requirements for Medicaid, Medicare, and other payers. 

Action Point: Invest in a HIPAA-compliant client management system to store and track client information, including assessments, care plans, service delivery, and progress reports. This system should also generate reports for billing and regulatory compliance. 

Tip: Choose a system that integrates with other healthcare providers’ EHRs, allowing for seamless coordination of care and information sharing between hospitals, clinics, and community providers. 

8. Secure Liability Insurance for Your Agency 

As a care coordination agency, it is essential to protect your business from potential legal claims, such as malpractice or negligence. Depending on the services you offer, you may need professional liability insurance, general liability insurance, and workers' compensation insurance for your staff. 

Action Point: Work with an insurance provider that specializes in healthcare or care management services to secure appropriate coverage for your agency. Ensure that your policy covers both individual care coordinators and your agency as a whole. 

Tip: Review your insurance policy annually to ensure it covers new services or staffing changes as your agency grows. 

9. Pass State Inspections and Maintain Ongoing Compliance 

Before your care coordination agency can begin operations, you may need to pass state inspections or meet specific accreditation standards. Additionally, your agency will need to maintain compliance with state and federal regulations governing patient care, privacy, and billing practices. 

Action Point: Prepare for any required state inspections or accreditation processes by ensuring that your policies, staff credentials, and facility meet regulatory standards. Keep documentation readily available for review. 

Tip: Conduct internal audits on a regular basis to ensure your agency remains compliant with all relevant regulations, especially regarding patient privacy (HIPAA) and billing practices for Medicaid and Medicare. 

Best Practices for Operating a Care Coordination Agency 

Based on Waiver Consulting Group’s expertise, these best practices will help ensure your care coordination agency operates efficiently and provides high-quality care: 

Develop Patient-Centered Care Plans: Tailor care coordination services to the individual needs of each client. Assess clients' medical, social, and community-based needs and create care plans that promote holistic health and well-being. 

Foster Collaboration Among Providers: Care coordination requires close communication with healthcare providers, social service agencies, and community organizations. Establish clear protocols for sharing information and coordinating care to ensure clients receive comprehensive support. 

Focus on Continuity of Care: Ensure that clients experience seamless transitions between different care settings, such as from hospital to home or from one healthcare provider to another. Effective communication and follow-up help prevent gaps in care and improve health outcomes. 

Maintain Strong Relationships with Clients: Building trust with clients is essential in care coordination. Establish regular check-ins, provide clear communication, and involve clients in decision-making related to their care plans. 

Invest in Staff Development: Ongoing education and professional development are crucial for care coordinators. Provide opportunities for staff to attend conferences, complete certifications, and stay up-to-date on new care models and best practices. 

Common Challenges and Solutions for Care Coordination Agencies 

1. Navigating Complex Licensing Requirements 

Care coordination agencies may need to meet diverse licensing requirements depending on the services they offer and the licensure of their staff. 

Solution: Consult with healthcare attorneys or licensing boards to ensure you meet the necessary state requirements for licensure. Ensure that all staff members maintain current licensure and certifications, particularly in social work or nursing. 

2. Managing High Caseloads 

Care coordinators often manage multiple clients with complex needs, leading to high caseloads and potential burnout. 

Solution: Implement a caseload management system to distribute work evenly among staff. Hire additional care coordinators as needed to maintain reasonable caseloads and ensure high-quality service delivery. 

3. Ensuring Compliance with Medicaid and Medicare Billing 

Medicaid and Medicare have strict documentation and billing requirements for care coordination services. Non-compliance can result in denied claims or audits. 

Solution: Use a Medicaid/Medicare-compliant EHR system to track services and generate accurate billing documentation. Regularly audit your billing practices to ensure compliance with payer requirements. 

State-Specific Considerations for Care Coordination Agencies 

Licensing and certification requirements for care coordination agencies vary by state. Below are a few state-specific considerations: 

California: Care coordinators working with Medi-Cal (California’s Medicaid program) may need to be licensed social workers (LSWs) or registered nurses (RNs). California requires that agencies comply with Medi-Cal managed care standards for care coordination. 

Texas: The Texas Health and Human Services Commission (HHSC) regulates care coordination agencies that serve Medicaid clients. Care coordinators must meet state licensure requirements for social work or nursing and adhere to Home and Community-Based Services (HCBS) guidelines. 

Florida: Care coordination agencies in Florida must follow Agency for Health Care Administration (AHCA) guidelines for Medicaid services. Care coordinators working with Medicaid clients may need to be licensed nurses or social workers. 

New York: In New York, care coordination for Medicaid clients is regulated by the New York State Department of Health (NYSDOH). Medicaid care coordinators may need to be licensed social workers or nurses, depending on the complexity of care provided. 

How Waiver Consulting Group Can Help 

Navigating the regulatory and compliance landscape for care coordination services can be complex. Waiver Consulting Group offers expert guidance to help you: 

Determine Licensing Requirements: We assist in identifying the specific licensure and certification requirements for care coordinators based on your state’s regulations. 

Complete Medicaid and Medicare Applications: Our team helps you apply to become a Medicaid and Medicare provider and ensures your billing practices meet compliance standards. 

Develop Care Coordination Protocols: We help you develop policies and procedures that ensure consistent, high-quality care delivery across your agency. 

Maintain Ongoing Compliance: Waiver Consulting Group provides tools and resources to help you track staff licensure, manage Medicaid documentation, and stay compliant with state and federal regulations. 

For more information, visit Waiver Consulting Group or schedule a consultation. 

Conclusion 

Starting a care coordination agency requires attention to licensure, certification, and compliance with healthcare regulations. By following the steps outlined in this guide and working with Waiver Consulting Group, you can ensure your agency is fully licensed, compliant, and ready to provide high-quality, patient-centered care. 

For personalized assistance, get started with Waiver Consulting Group today!