Care Coordinator

The hiring range for this position is $78,001 - $87,236. The full range for this position is $78,001 - $109,112. The Care Coordinator plays an important role in supporting older adults and individuals with long-term care needs in Kandiyohi County by coordinating services, conducting MnCHOICES assessments, and helping individuals access programs and supports that promote independence, safety, and quality of life.

Primary responsibilities include care coordination for Prime West Health Minnesota Senior Care Plus (MSC+) and Minnesota Senior Health Options (MSHO) products, Special Needs Basic Care (SNBC), Alternative Care and Elderly Waiver case management, and Relocation Service Coordination for nursing facility residents. This position works closely with individuals, families, healthcare providers, health plans, nursing facilities, service providers, and community partners to assess needs, develop person-centered service plans, coordinate services, and monitor ongoing eligibility and service effectiveness.

• Provide care coordination for individuals enrolled in Prime West Health Minnesota Senior Care Plus (MSC+) and Minnesota Senior Health Options (MSHO), and Special Needs Basic Care (SNBC) products
• Provide case management services for individuals receiving services through the Alternative Care and Elderly Waiver programs.
• Conduct ongoing assessments of client needs, strengths, preferences, goals, health and safety concerns, and available informal and formal supports.
• Develop, implement, monitor, and update person-centered care and service plans in collaboration with clients, families, providers, and other members of the care team.
• Complete comprehensive, person-centered MnCHOICES assessments to identify functional, health, psychological, environmental, and social needs and determine eligibility for applicable long-term services and supports.
• Provide individuals with information regarding available services and supports to assist them in making informed choices regarding their care and living arrangements.
• Provide Relocation Service Coordination to eligible nursing facility residents seeking to transition to community-based settings.
• Assist clients with identifying and accessing appropriate housing, healthcare, transportation, home and community-based services, financial resources, and other supports necessary to maintain community living.
• Coordinate services with healthcare providers, health plans, nursing facilities, home and community-based service providers, family members, legal representatives, and other community partners.
• Conduct client visits and maintain required contact with individuals receiving case management and care coordination services.
• Monitor client health, safety, service utilization, and progress toward identified goals and make adjustments to service plans as needs change.
• Complete eligibility-related documentation, service authorizations, assessments, case notes, care plans, referrals, and other required records accurately and within established timelines.
• Maintain knowledge of applicable federal and state regulations, Minnesota Department of Human Services requirements, health plan requirements, county policies, and program guidelines.
• Utilize electronic assessment, case management, documentation, and communication systems in the performance of assigned duties.
• Maintain confidentiality of client information and comply with applicable data privacy requirements.
• Participate in interdisciplinary care planning, case consultation, team meetings, training, and professional development activities.
• Maintain required MnCHOICES certification and complete required recertification and continuing training.
• Other duties as assigned.

• Bachelor’s degree in Social Work or a closely related human services field required.
• Registered Nurse or Public Health Nurse.
• Two (2) years of related experience preferred, or an equivalent combination of education and experience.
• Valid driver’s license and reliable transportation required.
• Must pass a criminal background check and meet DHS requirements for working with vulnerable populations.

• Knowledge of person-centered assessment, care planning, case management, and care coordination principles.
• Knowledge of or ability to learn Minnesota long-term services and supports, including Alternative Care, Elderly Waiver, MSC+, MSHO, MnCHOICES, and relocation services.
• Strong assessment and interviewing skills with the ability to identify client strengths, needs, risks, preferences, and…