Case Manager Long-term Care - Delaware; Kent and Castle County RN

Job Summary

This position 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. It is a full‑time, community‑based role that requires frequent travel within the assigned territory in Delaware, with a significant portion of time spent in members’ homes and nursing facilities, providing case management services for those enrolled in DSHP Plus LTSS and DSNP.

• Conduct regular in‑home and nursing facility visits to complete face‑to‑face needs assessments and follow up via telephone 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, social, and custodial needs in a nursing facility, home, or community‑based setting.
• Coordinate care across the continuum of services and assist members with physical, behavioral, LTSS, social, and psychosocial needs in the safest, least restrictive, and most cost‑effective manner.
• Authorize LTSS services following a comprehensive needs assessment.
• Coordinate HCBS services, Medicaid and DSNP benefits, and assess appropriateness of care and services in the community.
• Facilitate transitions to alternate care settings such as hospital to home or nursing facility to community setting using an integrated care team.
• Educate members or caregivers regarding health care needs, available benefits, resources, and services, including long‑term care options.
• Provide education, resources, and assistance to help members achieve plan‑of‑care goals and overcome obstacles to optimal care.
• Develop individualized care plans in conjunction with members or caregivers to identify needed services.
• Identify resources needed for a fully integrated care coordination approach and facilitate 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 physical, behavioral health providers, ICT, and discharge planners—to coordinate care needs and community resources.
• Assist members in developing, implementing, and amending a backup plan for gaps in provider coverage.
• Ensure approved support services are being delivered as outlined in the plan of care.
• Evaluate effectiveness of the service plan and make appropriate revisions in accordance with policy and state contractual requirements.
• Assist members in overcoming obstacles to optimal care through connection with community resources, provider communication, and action‑plan formulation.
• Document all case‑management services and interventions 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 or requested.

• Bachelor’s degree in Social Work or health, human, or education services with 3 years of experience in long‑term care, home health, hospice, public health, or assisted living.
• Master’s degree in Social Work or the same fields with 1 year of experience in long‑term care, home health, hospice, public health, or assisted living.
• Current State RN or LPN licensure.
• Current multi‑state licensure through the Enhanced Nurse Licensure Compact (eNLC) with 2 years of experience in long‑term care, home health, hospice, public health, or assisted living.
• High school degree or equivalent with three years of qualifying experience in case management of the aged, including management of behavioral health conditions, persons with physical or developmental disabilities, or HIV/AIDS populations.

• One year in home clinical or case‑management experience.
• Certified Case Manager (CCM).
• Licensed Bachelors Social Worker (LBSW).
• Licensed Masters Social Worker (LMSW).
• Licensed Clinical Social Worker (LCSW).
• Experience working with HIV/AIDS populations.
• Experience working with behavioral health populations.
• Experience working with developmental disabilities populations.
• Medicare and Medicaid experience.
• Managed care…