Assist members and families with ALTCS applications, renewals, and ongoing case management.
Complete required assessments including UAT, HNT, and related tools within mandated timeframes.
Develop, implement, and update Person-Centered Service Plans (PCSPs) in coordination with nursing staff.
Conduct home visits, phone contacts, and community visits for assessment and monitoring.
Coordinate services prior to hospital discharge and during transitions of care.
Monitor service delivery, identify gaps, and initiate follow-up or reassessment as required.
Provide supportive counseling, education, and referrals to address social, financial, and psychosocial needs.
Advocate for members with insurance programs, transportation services, and community resources.
Participate in hospital continuity of care meetings and interdisciplinary case conferences.
Maintain accurate, timely, and compliant documentation in electronic health records.
Prepare progress notes and reports to support ALTCS requirements and audits.
Identify, document, and report suspected abuse, neglect, exploitation, or self-neglect in accordance with tribal, state, federal, and organizational requirements.
Attend required meetings, trainings, and continuing education.
Perform other duties of similar nature or level as assigned by the Director of Nursing.
