Scope of Practice:
Planning, arranging and coordinating services and resources to maximize the functional independence, and economic and social wellbeing of clients. Includes screening to identify appropriateness of service, assessment of client needs (and the needs of the client’s family when appropriate), care plan development, authorization or referral for services, and ongoing client/service monitoring. Targeted to functionally and/or mild cognitively impaired individuals 60 years of age or older particularly persons receiving Medicare.
Essential Functions & Responsibilities:
1. Review intakes by Senior Service Supervisor, contacts client and if needed client’s family or social supports to conduct a thorough in home assessment of client’s needs.
2. Conducting in-home visits must consist of a culturally sensitive and client centered evaluation of client’s medical, mental health, benefits and entitlements, financial social and community-based needs.
3. Referring clients for DFTA funded services such as Meals on Wheels and Homecare. Explaining service, the client is eligible for and defining the Bi monthly and yearly contact that will be made by the case manager to assure smooth and continued service to the client. Other referrals if appropriate will be made at the time of the initial home visit. They may include friendly visiting, telephone reassurance, Nutritional Counseling, and Visiting Dr. Programs.
4. Document directly into the DFTA computer system and completes any other daily required forms of all services provided directly and indirectly to client care services and coordination of care plan.
5. Identifies client at risk for hospitalization or falls and works with community services to resolve or minimize risks. Assists client/family in emergency disaster planning. Maximizes client independence and safety through collaboration of all available resource, including family, friends and community services.
6. Attends and participates in meetings dealing with client problems, such as social/financial/family/relationships and as appropriate may have specific clients and or family involved in the process. Client/family participates in all decision-making resolutions of identified problems and in creating short and long term goal for ongoing independence of client.
7. Coordinates resources for client and acts as liaison and advocate with other community agencies to provide needed services. Assists in identifying unmet needs in the community and develops a network of referrals of client services.
8. Attends conferences and appropriate community meetings for informational and networking purposes and also to improve case management skills. Analyzes problems in delivery of services for maximizing client safety and self-care; defines alternatives if needed in selecting the appropriate options for resolving these problems.
Qualifications:
1. Education:
- MSW or related Master’s degree (e.g., social services, public administration, nursing, or public health) preferred when practicable and budget allows; or Bachelor’s level degree; or High school diploma or Associate degree with four years or more of casework experience in a community social service or social action program; or Registered Nurse with one year of satisfactory full-time paid experience as a nurse.
2.Experience:
- Case Management experience with home visits and knowledge of the elderly and benefits and entitlements.
3. Special Skills:
- Bilingual
- Team player, good time management skills, good communication skills and computer skills.
Physical Requirements and working Environment:
1. Travel by all forms of public transportation or car in the community; walk up stairs if no elevator.
2. Ability to communicate orally and in writing with regulatory agencies, outside agencies, clients, staff, co-workers, and vendors.
3. Visual ability to assess home environment for safety and security.
Pay: $60,000.00 - $65,000.00 per year
Benefits:
- Dental insurance
- Health insurance
- Vision insurance
Work Location: In person
