LTSS Service Coordinator managing service coordination functions for individuals in the IN PathWays for Aging program. Collaborating with healthcare teams for integrated care plans and support structure.
Responsibilities
Responsible for performing face to face program assessments (using various tools with pre-defined questions) 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
Uses tools and pre-defined identification process
Identifies members with potential clinical health care needs (including, but not limited to, potential for high-risk complications, addresses gaps in care) and coordinates those member’s cases (serving as the single point of contact) with the clinical healthcare management and interdisciplinary team to provide care coordination support
Manages non-clinical needs of members with chronic illnesses, co-morbidities, and/or disabilities, to ensure cost effective and efficient utilization of long-term services and supports
At the direction of the member, documents their short and long-term service and support goals in collaboration with the member’s chosen care team including caregivers, family, natural supports, service providers, and physicians
Identifies members that would benefit from an alternative level of service or other waiver programs
May also serve as mentor, subject matter expert or preceptor for new staff, assisting in the formal training of associates, and may be involved in process improvement initiatives
Submits 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 (Adult Protective Services, Law Enforcement)
Assists and participates in appeal or fair hearings, member grievances, appeals, and state audits
Requirements
BA/BS degree and a minimum of 2 years of experience working with a social work agency; or any combination of education and experience which would provide an equivalent background
Experience working with older adults in care management, provider or other capacity, highly preferred
Experience managing a community and/or facility-based care management case load, highly preferred
BA/BS degree field of study in health care related field preferred
Travels to worksite and other locations as necessary.
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