LTSS Service Coordinator – Case Manager

Responsibilities

• 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.
• Conducts assessments and develops a comprehensive Person Centered Support Plan (PCSP) and backup plan.
• Interfaces with Medical Directors and participates in interdisciplinary care rounds to support development of a fully integrated care plan.
• Engages the member’s circle of support and overall management of the individuals physical health (PH)/behavioral health (BH)/LTSS needs.
• Documents short and long-term service and support goals in collaboration with the member’s chosen care team that may include, caregivers, family, natural supports, service providers, and physicians.
• Identifies members that would benefit from an alternative level of service or other waiver programs.

• Requires BA/BS degree and a minimum of 2 years of experience working with a social work agency; or 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.
• BA/BS degree field of study in health care related field preferred.
• Bilingual in English/ Spanish strongly preferred.
• LTSS, case management, social work or hospital discharge planning experience preferred.

• Assessment Development
• Person Centered Support Plan (PCSP)
• Service Coordination
• Interdisciplinary Care Collaboration
• Goal Documentation

• Communication
• Collaboration
• Engagement