Responsible for 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
Conducts assessments and development of a comprehensive Person Centered Support Plan (PCSP) and backup plan
Interfacing with Medical Directors and participating in interdisciplinary care rounds
Engaging the member’s circle of support and overall management of the individuals physical health (PH)/behavioral health (BH)/LTSS needs
Responsible for performing face to face program assessments
Applies motivational interviewing techniques for evaluations, coordination, and management of an individual’s waiver (such as LTSS/IDD), and BH or PH needs
Coordinates those member’s cases with the clinical healthcare management and interdisciplinary team
Manages non-clinical needs of members with chronic illnesses, co-morbidities, and/or disabilities
At the direction of the member, documents their short and long-term service and support goals
Identifies members that would benefit from an alternative level of service or other waiver programs
May serve as mentor, subject matter expert or preceptor for new staff
Submits utilization/authorization requests to utilization management
Requirements
Requires BA/BS degree and a minimum of 2 years of experience working with a social work agency
Preferred Skills, Capabilities and Experiences: BA/BS degree field of study in health care related field preferred
Bilingual in English/ Spanish strongly preferred
LTSS, case management, social work or hospital discharge planning experience preferred
Benefits
merit increases
paid holidays
Paid Time Off
incentive bonus programs (unless covered by a collective bargaining agreement)