LTSS Service Coordinator – Case Manager

• Responsible for conducting service coordination functions for a defined caseload of individuals in specialized programs
• In collaboration with the person supported, facilitates 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
• Responsible for performing face to face program assessments for identification
• applying motivational interviewing techniques for evaluations, coordination, and management of an individual’s waiver
• Uses tools and pre-defined identification process, identifies members with potential clinical health care needs
• coordinates those member’s cases with the clinical healthcare management and interdisciplinary team
• Manages non-clinical needs of members with chronic illnesses, co-morbidities, and/or disabilities
• Assists and participates in appeal or fair hearings, member grievances, appeals, and state audits

• Requires BA/BS degree
• a minimum of 2 years of experience working with a social work agency
• any combination of education and experience which would provide an equivalent background
• Specific education, years, and type of experience may be required based upon state law and contract requirements
• Bilingual in English/ Spanish strongly preferred
• LTSS, case management, social work or hospital discharge planning experience preferred

Demonstrates expertise in conducting assessments and developing comprehensive Person Centered Support Plans (PCSP) while effectively coordinating care for individuals with physical and behavioral health needs. Proficient in applying motivational interviewing techniques and managing interdisciplinary team collaboration.

• Person Centered Planning
• Case Management
• Motivational Interviewing
• Interdisciplinary Team Collaboration
• Bilingual in English/Spanish

• Assessment Development
• Person Centered Support Plan (PCSP)
• Clinical Health Care Needs Identification
• Chronic Illness Management
• Social Work Experience
• LTSS Experience
• Hospital Discharge Planning

• Communication
• Collaboration
• Problem Solving

• BA/BS Degree

• Social Work Agency
• Member Grievances
• State Audits
• Fair Hearings