Description:
Reporting Office: North Central (Bristol)
Program: Money Follows the Person (MFP)
Covering Region/Community: North Central
Job Requirement: Must have BA Degree & minimum 2yrs of direct Case Management experience.
SUMMARY
Assists persons referred to the Money Follows the Person Rebalancing Demonstration who are targeted to ABI, CHCPE, PCA, and State Plan services in the interactive process of informed decision-making about community long-term services and supports. Serves a key role in the assessment, information and referral, care and engagement planning and implementation, access to supports and coordination with waiver programs. Works with individuals at the start of transitions up to three months to one year post transition to community. Performs all duties in a manner that fosters the achievement of the organization’s mission to identify choices and provide services to help people of all ages, abilities and incomes to live at home.
KEY RESPONSIBILITIES
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Conducts comprehensive, systematic, assessments that are person-centered with individuals, including family or representative as requested, conservators or guardians in the person’s preferred setting for the discovery, use, and screenings for all waiver systems. Follows up with referral source as to the outcome of the assessment.
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Discusses the individual’s current situation including the use of or interest in self direction, resources, existing family and community supports, special designations that carry health and/or service benefits, and any caregiver needs.
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Works with the individual to identify needs in the context of their self defined goals, strengths, values, preferences, as well as what is important to and for them.
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Uses motivational interviewing techniques to engage the individual in the development and implementation of an appropriate quality and cost-effective care plan based on the person’s goals, desired outcomes and specific choices.
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Works collaboratively in a cross-agency team environment to achieve benchmarks.
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Works with the individual to identify a full range of public and private programs/services available including self directed options, exploring available supports, service options and resources without personal bias.
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Explains the components of the program, service options, and Department of Social Services (DSS) guidelines, including eligibility, costs, how each may work with the person’s formal and informal supports and resources, and the pros and cons/costs and benefits of each option.
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Works with the individual to access services and supports identified in the care plan. Assists individuals with applications for all identified programs, services and supports, including functional eligibility/level of care determination and financial eligibility information.
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Shares the documented care plan with the individual and other relevant people as determined by them and review necessary steps for implementation. Works with the individual to identify any barriers to expedite access to services and supports and advocate with the person to develop and implement strategies to minimize or eliminate barriers.
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Works in close collaboration with DSS MFP Central Office, transition coordination and housing coordination Staff to ensure time efficiencies and smooth, prompt transition to community.
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Works in close collaboration with UCONN and DSS MFP Central Office to pilot and inform new services, process and tools, including new assessment tools.
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Ensures transitions from Specialized Care Manager to waiver care planning staff.
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Performs additional related duties as assigned.
COMPETENCIES
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Assertiveness: Communicates position directly and honestly while demonstrating respect for others.
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Client Focus: Builds effective relationships with clients, identifies client expectations, tries to see issues from their point of view; offers practical solutions to problems.
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Decision Making Skills: Gathers and analyzes information, considers consequences, and arrives at a timely decision that meets organizational goals.
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Diversity: Fosters an environment of belonging and inclusion. Values cultural, ethnic, racial and gender diversity. Committed to equity.
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Ethics & Integrity: Makes decisions and conducts self-consistent with organization principles.
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Listening: Supports speakers and interprets their messages in such a way that effective communication takes place.
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Personal Accountability: Accepts responsibility for own actions, including failure. Embraces experiences as learning opportunities and not chances to blame.
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Problem Solving: Gathers and analyzes information, identifies goals, explores, and selects solutions, implements an action plan, and evaluates results.
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Time Management: Allocates time efficiently to the most important issues and knows what not to spend time on; completes work in a timely fashion.
Requirements:
Education
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Bachelor’s degree in administration, social work, nursing, public health, psychology, counseling or gerontology or related field required.
Experience
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A Bachelor’s degree in nursing, health, social work, gerontology or a related field may be substituted for one year of experience.
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Must have a minimum of two years experience in health care or human services (including but not limited to community, hospital, institution or behavioral health). Work experience with older adults and/or people with disabilities preferred. Bachelor’s degree in fields related to care management preferred (social work, counseling, nursing, mental health, psychology, gerontology, sociology, RN (licensed in the State of CT), rehabilitation, public health, or human services).
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Experience in conducting comprehensive, systematic, person-centered assessments in community settings, homes, hospitals and nursing homes.
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Strong advocacy and communication skills.
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Knowledge of chronic conditions and management strategies.
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Strong understanding of the philosophy and importance of person centeredness, self-direction/self- determination and independent living.
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Knowledgeable of financial aspects such as Medicaid, Medicare, managed Medicare and pooled trusts.
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Understanding of Connecticut Medicaid waivers system and other appropriate programs, with a solid knowledge of community resources.
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Experience in building rapport and relationships with individuals, families and community resources using motivational interviewing techniques.
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Understands and practices risk assessment and risk mitigation.
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Experience with interviewing, observation and analysis.
Other
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On occasion may need to work non-traditional/flexible hours.
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May travel throughout the state.
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Reliable transportation, valid driver’s license and current automobile insurance are required.
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CCCI Job Code: 6184
Physical Requirements
Physical Activity Approximate Percentage of Time Spent in this Activity
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Bending 5%
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Climbing (e.g. stairs) 5%
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Keyboarding 60%
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Kneeling 5%
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Lifting (indicate maximum weight to be lifted) 30 lbs. (small office equipment, files, etc.)
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Reaching 5%
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Sitting 55%
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Standing 20%
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Using Telephone 60%
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Walking 20%
Work Environment (a brief description)
Work is performed in various environments including office, client homes, hospitals, nursing homes and other locations. Employees can be exposed to adverse driving conditions and the varying conditions associated with a wide range of home situations.
The physical requirements and description of the work environment are representative of what an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions.
