The Care Coordinator will provide coordinated LTSS care management services as an integrated member of care management team with a case load of up to 110 youth and adult enrolless in need of services.
Work collaboratively and effectively with care management, including Assigned or Engaged Enrollee, medical team and other providers to provide LTSS care management services.
Utilize the Comprehensive Assessment results from the ACO or MCO, and work with Assigned or Engaged Enrollee to develop or update the LTSS Care Plan within 90 days of assignment.
Ensure that the LTSS Care Plan meets the requirements of EOHHS and notify the ACO or MCO if changes have occurred to Assigned or Engaged Enrollee’s functional status, including Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) needs, since the completion of the Comprehensive Assessment.
Ensure the Assigned or Engaged Enrollee receives necessary assistance and accommodations to prepare for, fully participate in, and to the extent preferred, direct the care planning process. Ensure that the Assigned or Engaged Enrollee receives assistance in understanding LTSS terms and LTSS concepts, including but not limited to information on their functional status; how family members, social supports and other individuals of their choosing can be involved in the care planning process; self-directed care options and assistance available to self-direct care; and LTSS services or programs that are available to meet their needs and for which they are potentially eligible.
Inform the Assigned or Engaged Enrollee about his or her options for specific LTSS services and programs and providers that may meet their needs.
Conduct an assessment of the Assigned or Engaged Enrollee for social services and identify community and social services and resources that may support the health and wellbeing of the Assigned or Engaged Enrollee.
Conduct assessment for Flexible Services for all Assigned or Engaged Enrollees who are enrolled in an ACO. If Flexible Services are identified, make recommendation to ACO for approval.
BA in social work, human services, nursing, psychology, sociology, or related field from an accredited college/university OR an Associate’s degree and at least one year professional experience in the field OR at least three years of relevant professional experience. Experience working with individuals with complex LTSS needs desired. Care Coordination experience preferred.
Experience in navigating individual and family service systems and demonstrated the capacity to work collaboratively and effectively with families and community-based colleagues.
Ability to use Care Management Software to document and coordinate services.
Must be able to perform each essential duty satisfactorily.
Strong interpersonal skills in terms of developing a working relationship with a variety of individuals in a variety of context. Ability to communicate effectively verbally and in writing.
Strong organization skills with Attention to detail, Multi-tasking skills, Prioritization skills, Analytical skills, Problem-solving skills and Team skills.
Strongly prefer that a candidate will have a demonstrated understanding of and competence in serving culturally diverse populations
Commitment to MCCN values and mission.
Ability to travel on a regular basis; Must have valid driver’s license and access to auto.
Ability to read and speak English. Fluency in other languages, especially Spanish, a plus.