LTSS Service Coordinator responsible for assessments and coordinating care for individuals with specialized programs. Engaging with members and their support systems while working primarily in the field.
Responsibilities
Conducting service coordination functions for a defined caseload of individuals in specialized programs
Facilitating 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 using various tools with pre-defined questions
Applying motivational interviewing techniques for evaluations, coordination, and management of an individual’s waiver needs
Coordinating those member’s cases with the clinical healthcare management and interdisciplinary team to provide care coordination support
Managing non-clinical needs of members with chronic illnesses, co-morbidities, and/or disabilities
Documenting short and long-term service and support goals in collaboration with the member’s care team
Requirements
Requires BA/BS degree and a minimum of 2 years of experience working with a social work agency
Bilingual in English/ Spanish strongly preferred
BA/BS degree field of study in health care related field preferred
LTSS, case management, social work or hospital discharge planning experience preferred
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