Conducting service coordination functions for a defined caseload of individuals in specialized programs
Facilitates the Person Centered Planning process that documents the member’s preferences, needs and self-identified goals
Conducting assessments, development of a comprehensive Person Centered Support Plan (PCSP) and backup plan
Interfacing with Medical Directors and participating in interdisciplinary care rounds to support development of a fully integrated care plan
Engaging the member’s circle of support and overall management of the individuals physical health (PH)/behavioral health (BH)/LTSS needs
Performing face to face program assessments for identification, applying motivational interviewing techniques for evaluations
Coordination and management of an individual’s waiver (such as LTSS/IDD), and BH or PH needs
Managing non-clinical needs of members with chronic illnesses, co-morbidities, and/or disabilities
Documenting their short and long-term service and support goals in collaboration with the member’s chosen care team
Submitting utilization/authorization requests to utilization management with documentation supporting and aligning with the individual’s care plan
Responsible for reporting critical incidents to appropriate internal and external parties such as state and county agencies

Requires BA/BS degree and a minimum of 2 years of experience working with a social work agency
Bilingual in English/ Spanish strongly preferred
LTSS, case management, social work or hospital discharge planning experience preferred

LTSS Service Coordinator – Case Manager, Region D: Highlands/Hardee

Key skills