General Statement of Duties: Provide coordinated Long Term Services and Supports (LTSS) care management services as an integrated member of the care management team to adult and youth Enrollees in need of services.
Work collaboratively and effectively with care management team, including Assigned or Engaged Enrollees, their family/caregivers, medical team, and other providers to provide LTSS care management services.
Utilize the Comprehensive Assessment results from the Accountable Care Organization (ACO)/Managed Care Organization (MCO), and work with Assigned or Engaged Enrollee to develop or update the LTSS Care Plan within 90 days of assignment.
Ensure that the LTSS Care Plan meets the requirements of EOHHS and notify the ACO/MCO if changes have occurred to Engaged Enrollee’s functional status, including Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) needs, since the completion of the Comprehensive Assessment.
Ensure the Engaged Enrollee receives the necessary assistance and accommodations to prepare for, fully participate in and to the extent preferred, direct the care planning process. Ensure that the Engaged Enrollee receives assistance in understanding LTSS terms and LTSS concepts, including but not limited to information on their functional status; how family members, social supports and other individuals of their choosing can be involved in the care planning process; self-directed care options and assistance available to self-direct care; and LTSS services or programs that are available to meet their needs and for which they are potentially eligible.
Inform the Engaged Enrollee about his or her options for specific LTSS services and programs and providers that may meet their needs.
Conduct an assessment of the Engaged Enrollee for social services and identify community and social services and resources that may support the health and well being of the Assigned or Engaged Enrollee.
Conduct assessment for Flexible Services for all Engaged Enrollees who are enrolled in an ACO. If Flexible Services are identified, make recommendation to ACO for approval.
Provide LTSS subject matter expertise to health care, behavioral health, and social service providers.
Coordinate all aspects of service delivery and promote integration with healthcare providers, Behavioral Health (BH) providers, LTSS providers and community/social services providers that the Engaged Enrollee may be receiving, as outlined in the LTSS Care Plan.
Participate in Enrollee’s care team meetings to ensure effective communication among all disciplines involved in the individual’s care.
Provide health and wellness coaching as directed by the Engaged Enrollee’s care team and as indicated in the Enrollee’s LTSS Care Plan.
Maintain regular contact with Engaged Enrollee to monitor and coordinate LTSS Care Plan including quarterly face-to-face meetings.
Update the LTSS Care Plan to reflect the Engaged Enrollee’s changing needs.
Complete all required documentation in a timely manner.
Provide outreach and engagement services to individuals as needed including transportation for services related to their Care Plan.
Provide transition planning and transition coordination to Engaged Enrollee including follow-up support post discharge.
Ensure that individuals receiving services are treated with dignity and respect in accordance with MCCN Human Rights Policy.
Perform duties in accordance with the agency’s policies and procedures.
Strictly follow all agency Performance Standards.
Perform other related work duties as needed or as assigned by supervisor.
- Bachelor’s degree in social work, human services, nursing, psychology, sociology, or related field from accredited college/university OR an Associate’s degree and at least one year professional experience in the field OR at least three years of relevant professional experience. Experience working with individuals with complex LTSS needs desired. Care Coordination experience preferred.
- Experience navigating individual and family service systems and demonstrated the capacity to work collaboratively and effectively with families and community-based colleagues.
- Ability to use Care Management Software and document and coordinate services.
- Must be able to perform each essential duty satisfactorily.
- Strong interpersonal skills in terms of developing a working relationship with a variety of individuals in a variety of context. Ability to communicate effectively verbally and in writing.
- Strong organizational skills with attention to detail, multi-tasking skills, prioritization skills, analytical skills, problem-solving skills and team skills.
- Strongly prefer that a candidate will have a demonstrated understanding of and competence in serving culturally diverse populations.
- Commitment to MCCN values and mission.
- Ability to travel on a regular basis. Must possess a valid driver’s license in state of residence, and have own means of transportation.
- Ability to read and speak English. Fluency in other language especially Spanish, Portuguese, Cape Verdean Creole, and/or Haitian Creole preferred.