- As a member of the Primary Care Team, participate in initial and ongoing assessments of the health and functional status of enrollees, including determining appropriateness for institutional long-term care services and developing community-based care plans and related service packages necessary to improve or maintain an enrollee's health and functioning
- Arrange, coordinate and authorize the provision of appropriate long-term care and social support services for enrollees (with the agreement of the primary care team and in accordance with requirements set forth by the plan).
- Monitor the appropriate provision and functional outcomes of community long-term care services which have been authorized by the primary care team
- Track enrollee transfers from one setting to another (for example, hospital to home or nursing home to adult day health) and adjust service plan as deemed appropriate by the PCT and in accordance with requirements set forth by the plan.
- Participate in case conferences with the PCP, Nurse Care Managers, and representatives from other disciplines to identify the optimal plan of care for plan's members
- Book and change medical appointments for enrollees when requested by the PCP.
- Respond in a timely manner to enrollee service requests
- In collaboration with the PCT, the enrollee, the enrollee's designated representative and providers of community-based services in determining appropriate discharge plans after admission to an institution
- Prepare documentation for enrollee files and ensure appropriate and time entries and updates of enrollee information available in the centralized enrollee record
- Have working knowledge of SAMS, and plan's Centralized Enrollee Record in order to enter and retrieve data protocols
- Perform all services in accordance with state and federal law and written plan's management protocols
- Attend and participate in agency and departmental meetings and trainings as required
- Perform other duties as assigned
- Knowledge and skills necessary to work successfully in the interdisciplinary team and provide or arrange community long-term care.
- Ability to assess clients and their needs and knowledge of the community-based service network.
- Possess excellent interpersonal and problem solving skills
- Ability to work with a diverse population
- Access to transportation is desirable
- Licensed Social Worker by the Commonwealth of Massachusetts, with annual and continuing education units in Mental Health practice; or,
- A Bachelor's degree in social work or human services, and at least 2 years professional experience working in a human service field with the target population (disabled adults ages 21 and older, mental health and substance abuse).
- The employee must be able to carry a10 to 15 pound load.
- The employee is regularly required to talk or hear.
- The employee frequently is required to stand; walk; use hands to finger, handle or feel; and reach with hands and arms.
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Long Term Support Coordinator - Boston, United States - Boston Senior Home Care , Inc
Description
Job Title:
Long Term Support
Job Function:
Direct Services
Department:
One Care Program
Reports To:
Program Manager
FLSA:
Non-Exempt
Classification:
Regular Full-time (35 Hours)
Grade: 8
JOB DESCRIPTION
Overview/Summary:
The Long Term Support Services Coordinator (LTSC) is the care manager assigned to work with One Care plan enrollees and is a member of the Primary Care Team (PCT).
The LTSC is responsible for coordinating and providing community social services to One Care Plan enrollees in accordance with the plan's policies, procedures, and practices.
The LTSC assists in promoting the plan's enrollee's independent functioning in the most appropriate, least restrictive setting.Essential Functions
Essential Job functions:
Duties _______ through _______are designated as ADA Essential Functions and must be performed in this job. All other job duties are secondary functions. [TBD]
These may include but not be limited to:
ADL and IADL assist; housing; home-delivered meals; transportation
Must clear CORI background check
Work Environment
This job operates in a professional office environment. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets.
Physical Demands
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.
This is a full-time position. Days and hours of work are Monday through Friday, 9:00 a.m. to 5 p.m.
Travel
This position required up to 25% travel. Must be able to travel to the community to perform visits at consumers' homes (may have limited accessibility), and travel under all weather conditions
AAP/EEO Statement:
Equal Employment Opportunity/Affirmative Action/Male/Female/Veteran/Disabled Boston Senior Home Care affirms and supports diversity and inclusion in our workforce and recognizes all EEOC Factors.
Other Duties:
Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job.
