1. Provide overall supervision to Care Coordinators and track and ensure compliance with completion of required training.
2. Work collaboratively and effectively with care management, including Assigned or Engaged Enrollee, medical team and other providers to coordinate the delivery of LTSS care management services.
3. Utilize the Comprehensive Assessment results from the ACO or MCO, and work with the Care Coordinator to ensure approval of the LTSS Care Plan within 90 days of assignment.
4. Utilize Care Management Tool and database to track staff work activities including outreach, intake, assessment, service planning and delivery, referrals and linkages to community-based organizations, follow-up, collaboration with collateral contacts, documentation, confidentiality, and contact standards.
5. Ensure the LTSS Care Plans meet the requirements of EOHHS and ensure all updates and changes are reported to the ACO or MCO if they occur after the since the completion of the Comprehensive Assessment.
6. Ensure Coordinators provide assistance and accommodations for Engaged Enrollees to understand LTSS terms and LTSS concepts, and self-directed care options.
7. Maintain an updated database of LTSS services or programs that are available for Care Coordinators to access to assist Engaged Enrollees to understand what they are potentially eligible to receive.
8. Coordinate the provision of an accessible database of local community and social services and resources that based on assessment, may support the health and wellbeing of the Assigned or Engaged Enrollee.
9. Based on assessment, ensure that recommendations for Flexible Services for all Assigned or Engaged Enrollees are submitted to ACO for approval.
10. Provide LTSS subject matter expertise to health care, behavioral health, and social services providers.
11. Maintain oversight of all aspects of service delivery and promote integration with health care providers, BH providers, LTSS providers and community/social service provides that the Assigned or Engaged Enrollee may be receiving, as outlined in the LTSS Care Plan.
12. Ensure that regular contact with Engaged Enrollee and Care Coordinator is maintained and documented.
13. Ensure the LTSS Care Plans are updated to reflect the Assigned or Engaged Enrollee’s changing needs.
14. Complete all required documentation and reporting in a timely manner.
15. Coordinate transition planning for Engaged Enrollees including follow-up support post discharge.
16. Ensure that individuals receiving services are treated with dignity and respect in accordance with MCCN Human Rights Policy.
17. Serves as point of contact for crisis intervention services.
18. Perform all duties in accordance with the agency’s policies and procedures.
19. Strictly follow all agency Performance Standards.
1. Bachelor’s degree in social work, human services, nursing, psychology, sociology, or related field from an accredited college/university and at least three years of relevant professional experience.
Experience working with individuals with complex LTSS needs a plus. Master’s prepared preferred.
2. Supervisory experience.
3. Ability to use Care Management Software to document and coordinate services.
4. Must be able to perform each essential duty satisfactorily. Organized and efficient. Demonstrates sound judgment and discretion.
5. Ability to communicate effectively verbally and in writing.
6. Strongly prefer that a candidate will have a demonstrated understanding of and competence in serving culturally diverse populations
7. Commitment to MCCN values and mission.
8. Ability to travel and must have valid driver license and access to auto.
9. Ability to read and speak English, bilingual preferred.