Community Based Waiver Service Coordinator; RN, LSW, LISW - Cincinnati​/Dayton​/Toledo, OH; Mobi

Job Summary

The Community Based Waiver Service Coordinator, Duals Integrated Care manages and coordinates services for individuals requiring long-term care support and eligible for community-based waiver programs, ensuring members receive necessary services and supports to live independently while coordinating care across healthcare and social service systems.

• Engage with members in a variety of community-based settings to establish an effective care coordination relationship, considering the cultural and linguistic needs of each member.
• Conduct comprehensive assessments to determine the needs of members eligible for community-based waiver services.
• Develop individualized service plans that outline the necessary supports and services, ensuring they align with the individual’s preferences and goals.
• Serve as the primary point of contact for members and their families, coordinating care across multiple providers and services, including healthcare, social services, and community resources.
• Facilitate access to necessary services such as home health care, personal care assistance, transportation, and other community-based supports.
• Regularly monitor the implementation of service plans to ensure that services are being delivered effectively and that individual needs are being met.
• Conduct follow-up assessments to evaluate the effectiveness of services and make adjustments to person-centered care plans as needed.
• Advocate for the rights and needs of members receiving waiver services, ensuring they have access to the full range of benefits and supports available to them.
• Empower members and their families/caregivers to make informed decisions about their care and support options.
• Build and maintain relationships with healthcare providers, community organizations, and other stakeholders to facilitate integrated care.
• Lead and collaborate with interdisciplinary care team (ICT) to discuss individual cases, coordinate care strategies, and create holistic care plans that address medical and non-medical needs.
• Provide education and resources to members and their families/caregivers about available services, benefits, and community resources.
• Offer guidance on navigating the healthcare system and accessing necessary supports.
• Maintain accurate and up-to-date records of member interactions, care/service plans, and progress notes.
• Assist in preparation of reports and documentation required for compliance with state and federal regulatory requirements.
• Respond to crises or emergencies involving members receiving waiver services, coordinating immediate interventions and support as needed.
• Evaluate member satisfaction through open communication and monitoring of concerns or issues.
• Regularly travel to conduct member, provider, and community-based visits as needed per regulatory requirements of the program.
• Report abuse, neglect, or exploitation of older adults as a mandated reporter per State law.
• Verify and collaborate with Job and Family Service to establish and/or maintain Medicaid eligibility.
• On-call responsibilities as assigned.
• Perform any other job duties as requested.

• Nursing degree from an accredited nursing program or Bachelor’s degree in health care field or equivalent years of relevant work experience is required.
• Minimum of 1 year paid clinical experience in home and community-based services is required.
• Medicaid and/or Medicare managed care experience is preferred.

• Intermediate proficiency level with Microsoft Office, including Outlook, Word, and Excel.
• Prior experience in care coordination, case management, or working with dual-eligible populations is highly beneficial.
• Understanding of Medicare and Medicaid programs, and community resources and services available to dual-eligible beneficiaries.
• Strong interpersonal and communication skills to effectively engage with members, families, and healthcare providers.
• Awareness of and sensitivity to the diverse backgrounds and needs of the populations served.
• Ability to manage multiple cases and priorities while maintaining attention to detail.
• Adhere to code of ethics that aligns with professional…