In PersonLocal travel is required 50–75%; regional travel and overnight off-premises meetings, conferences, or trainings are also required.
About the job
Requirements
A bachelor's degree in social work, psychology, sociology, or a related field, or a Registered Professional Nurse license to practice in Georgia.
Two years of experience in a human services or health-related field.
Ability to coordinate and communicate effectively with clients, service providers, the general public, and staff members.
Skills in establishing and sustaining interpersonal relationships.
Knowledge of human behavior and gerontology.
Skills in team building and group dynamics.
Knowledge of community organization and service system development.
Problem-solving skills and techniques.
Knowledge and skill in social and health service intervention techniques and methodology.
Proficiency with Windows 95/98 and Microsoft Word, with the ability to learn AIMS and CHAT.
A valid state driver's license.
Ability to respond appropriately to emergency situations.
Ability to read and interpret written, oral, diagram, or schedule instructions.
Ability to apply common-sense understanding to detailed written or oral instructions and deal with problems.
Ability to lift up to 11 pounds and occasionally up to 25 pounds.
Responsibilities
Manage a minimum caseload of 75 members or clients.
Develop, implement, monitor, and update comprehensive person-centered care plans with clients, families, caregivers, physicians, and service providers.
Meet standards for new-admission contacts, monthly telephone contacts, in-home visits, and 90-day reassessments, documenting activities in the designated data management system.
Conduct monthly telephone contacts and face-to-face visits every 90 days to assess needs, monitor service effectiveness, and ensure care plan goals are met.
Act as a liaison among members or clients, families, providers, physicians, and community partners to resolve concerns, address non-compliance issues, and coordinate services.
Create and adjust service orders and troubleshoot billing concerns.
Broker and coordinate services needed to implement person-centered care plans.
Arrange and coordinate community-based services and support resources.
Collaborate with agencies, providers, and organizations involved in member or client care to ensure continuity and quality of services.
Participate in multidisciplinary case conferences to review care plans, hospitalizations, levels of care, non-compliance, and ongoing needs.
Maintain knowledge of applicable state regulations, program requirements, policies, and procedures governing service delivery.
Review and monitor service utilization and costs for compliance with program guidelines and funding limitations.
Oversee service delivery to verify that members or clients receive appropriate, effective, and person-centered care.
Maintain accurate, complete, and timely documentation according to agency and program requirements.
Report suspected abuse, neglect, or exploitation to appropriate agencies and regulatory entities as required.
Communicate with eligibility and benefits agencies regarding program eligibility, renewals, and related matters.
Assist members or clients with appeals and hearings, including preparing and submitting required documentation and records.
Collaborate with hospitals, home health agencies, nursing facilities, social workers, community organizations, and other stakeholders to support member or client well-being.
Attend required network, training, quarterly, team, and other program-related educational meetings.
Maintain current program manuals, policies, and reference materials.
Adhere to HIPAA regulations and confidentiality requirements to protect member or client information.
Perform other duties as assigned.
Description
DEPARTMENT: Health Programs Department
ACCOUNTABILITY: Reports to CCSP Program Manager
STATUS: Exempt, Full-time- TBD schedule
JOB SUMMARY
Provides comprehensive case management services for a caseload of 75+ members with complex health, long-term care, and social service needs. Develops, implements, and monitors person-centered care plans in collaboration with members, families, caregivers, healthcare providers, and community partners. Conducts ongoing assessments through regular phone and in-home visits to evaluate needs, coordinate services, and ensure care plan goals are achieved. Serves as a liaison among clients, providers, and community agencies to facilitate access to resources, resolve concerns, and maintain continuity of care. Monitors service utilization, program compliance, and quality outcomes while maintaining accurate documentation and adherence to regulatory requirements, HIPAA standards, and agency policies. Participates in multidisciplinary care team meetings, supports eligibility and appeals processes, and advocates for member well-being, independence, and access to appropriate services. Serves large geographic areas which may include parts of one large county and/or many small counties. Travel involved.
DUTIES AND RESPONSIBILITIES
Essential Functions
• Manages a minimum caseload of 75 members/clients.
• Develops, implements, monitors, and updates comprehensive, person-centered care plans in collaboration with the client, family, caregivers, physicians, and service providers.
• Meets standards of promptness for new admission contacts, monthly phone contacts, in-home visits, and 90-day reassessments, documenting all activities within the designated data management system.
• Conducts monthly telephone contacts and face-to-face visits every 90 days to assess needs, monitor service effectiveness, and ensure care plan goals are being met.
• Acts as a liaison between members/clients, families, providers, physicians, and community partners to resolve concerns, address non-compliance issues, and coordinate services.
• Creates and adjusts service orders as necessary and troubleshoots billing concerns.
• Brokers and coordinates services as needed to support the implementation of the person-centered care plan.
• Arranges and coordinates community-based services and other support resources as appropriate.
• Communicates and collaborates with all agencies, providers, and organizations involved in the member's/client's care to ensure continuity and quality of services.
• Participates in multidisciplinary case conferences with nursing staff, medical directors, supervisors, and service providers to review care plans, hospitalizations, levels of care, areas of non-compliance, and ongoing needs.
• Maintains knowledge of applicable state regulations, program requirements, policies, and procedures governing service delivery.
• Reviews and monitors service utilization and costs to ensure compliance with program guidelines and established funding limitations.
• Oversees service delivery to verify that members/clients receive appropriate, effective, and person-centered care.
• Maintains accurate, complete, and timely documentation in accordance with agency and program requirements.
• Reports suspected abuse, neglect, or exploitation to appropriate agencies, including LTCO, APS, OIG, ORS, CPS, or other regulatory entities, as required.
• Communicates with eligibility and benefits agencies regarding program eligibility, renewals, and related matters.
• Assists members/clients with appeals and hearings, including the preparation and submission of required documentation and records.
• Collaborates with hospitals, home health agencies, nursing facilities, social workers, community organizations, and other stakeholders to support member/client well-being.
• Attends required network meetings, trainings, quarterly meetings, team meetings, and other program-related educational opportunities.
• Maintains current program manuals, policies, and reference materials as required.
• Adheres to all HIPAA regulations and confidentiality requirements to ensure the privacy and security of member/client information.
• Performs other duties as assigned.
Requirements
EDUCATION, EXPERIENCE AND SKILL REQUIREMENTS
Education:
· Bachelor’s degree in social work, Psychology, Sociology or related field or Registered Professional Nurse currently licensed to practice in the state of Georgia
Knowledge and Experience:
· Two (2) years of experience in human services or health related field
Skills:
· Ability to effectively coordinate and communicate with clients, services providers, general public, and other staff members
· Skills in establishing and sustaining interpersonal relationships
· Knowledge in human behavior, gerontology
· Skills in team building and group dynamics
· Knowledge of community organization and service system development
· Problem solving skills and techniques
· Knowledge and skill in social and health service intervention techniques and methodology
· Proficient in Windows 95/98, MS Word and ability to learn AIMS and CHAT
Licensure and Certification
· Valid State Driver’s License
PHYSICAL AND MENTAL DEMANDS
The physical and mental demands described are representative of those that must be met by an employee to successfully preform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions of the job, on a case-by-case basis.
· Regularly required to use hands to write, use computer, operate a motor vehicle, use hand-held device and telephone, and manipulate documents.
· Regularly required to read documents and write neatly, legibly, and transcribe accurate information and numbers/values.
· Continually engages in activities that require talking and hearing
· Frequent: Standing, sitting, walking, bending, repetitive use of hands, simple grasping and fine hand manipulation, pushing, and pulling. Occasionally required to lift or reach above shoulder level, climb, twist, squat, kneel, crouch or crawl.
· Must be able to lift up to 11 pounds, and occasionally up to 25 pounds.
· Ability to respond appropriately to emergency situations.
· Ability to read and interpret a variety of instructions in written, oral, diagram, or schedule form.
· Ability to apply common sense understanding to carry out detailed written or oral instructions.
· Ability to deal with problems.
· Some local and regional travel required
· Local Travel required (50-75%)
· Attendance at off-premises meetings, conferences or trainings. (25%, overnight)
WORK ENVIRONMENT
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of the job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions of the job, on a case-by-case basis.
· This job operates in an office environment. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines.
· Temperature ranges from normal indoor climate-controlled environment in buildings or vehicles, various outdoor conditions and temperature extremes encountered during off-site travel, and unpredictable indoor environmental conditions encountered during off-site travel, and unpredictable indoor environmental conditions encountered at off-site locations.
· Noise level is generally quiet to moderate.
The Legacy Link, Inc. is an Affirmative Action/Equal Opportunity Employer.