This job serves as the single point of contact for members to coordinate all of the member’s care needs across the various service delivery systems and community supports. This is a full time community based position requiring frequent travel within the assigned territory in DE. The incumbent will travel to members’ homes, nursing facilities, and other community based setting for individuals enrolled in DSHP Plus LTSS.
- Travel to members’ homes, nursing facilities, and other community based settings in order to complete face to face needs assessments with subsequent telephonic contact with the member in accordance with state and national guidelines, policies, procedures, and protocols.
- Assess, plan, coordinate, implement and evaluate care for eligible members with chronic and complex health care, social service and custodial needs in a nursing facility or home and community-based care setting.
- Coordinate care across the continuum of services and assisting members physical, behavioral, long term services and supports (LTSS), social, and psychosocial needs in the safest, least restrictive way possible while considering the most cost-effective way to address those needs.
- Facilitate authorization, coordination, continuity and appropriateness of care and services in community or HCBS.
- Facilitate transitions to alternate care settings such as hospital to home, nursing facility to community setting using an integrated care team to address the member’s specific needs.
- Educate members or caregivers regarding health care needs, available benefits, resources and services including available options for long term care community or facility-based service delivery.
- Provide education, resources, and assistance to help members achieve goals as outlined in their plan of care and to overcome obstacles to achieving optimal care in the least restrictive environment.
- Develop a plan of care in conjunction with members or caregivers to identify services to meet the member’s specific needs, and goals.
- Identify resources needed for a fully integrated care coordination approach including facilitating referrals to special programs such as Disease/Chronic Condition Management, Behavioral Health, and Complex Case Management.
- Collaborate with the member's health care and service delivery team including the DSHP Plus LTSS Member Advocate, ICT, and discharge planners, to coordinate the care needs and community resources for the member in order to maintain the member in the least restrictive safe environment possible.
- Assist members in developing, implementing and amending a back-up plan for gaps in provider coverage.
- Ensure approved support services are being provided as outlined in the plan of care.
- Evaluate the effectiveness of the service plan and making appropriate revisions as needed in accordance with per policy & procedures and state contractual requirements.
- Assist members in overcoming obstacles to optimal care through connection with community resources, including communicating with providers and formulating an appropriate action plan.
- Document all case management services and intervention in the electronic health record.
- Adhere to all company, State and Federal requirements related to privacy practices, HIPAA, and quality performance standards.
- Perform other duties as assigned/requested.
- Bachelor's degree in Social Work and 3 years of experience in long-term care, home health, hospice, public health, or assisted living
- Master’s degree in Social Work and 1 year of experience in long-term care, home health, hospice, public health, or assisted living
- Registered Nurse or Licensed Practical Nurse and 2 years of experience in long-term care, home health, hospice, public health, or assisted living
- One year in home clinical or case management experience
- Medicare and Medicaid experience
- Managed care experience
- Working flexible hours to meet member’s needs
- Proficiency in PC-based word processing and database documentation (Word, Excel, Internet, Outlook)
- Reliable transportation daily to be able to travel within assigned territory
- Ability to meet regulatory deadlines.
- Has a dedicated home work space used only for business purposes and is able to comply with all telecommuter policies.
- Experience in geriatric special needs, behavioral health, home health
- Understanding of the importance of cultural competency in addressing targeted populations.
- Experience with electronic documentation system(s)
- Experience with cost neutrality and budgeting
SCOPE OF RESPONSIBILITY
Does this role supervise/manage other employees?
Is Travel Required?
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
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