GENERAL DESCRIPTION: Performs assessment of and coordinates activities related to Care Management participant’s social, emotional, and financial needs. Plans for care to meet these needs and assess entitlement programs and basic need services. Implements long term care services plans.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
Conducts functional assessment of client health needs.
Using a person-centered approach, develop a plan of care in conjunction with participant, all allies participant wishes to be involved in the planning process and participant’s physician. Assist participant with setting both frequency and duration of services, and implement plan as approved by participant.
Provides advocacy and arrange for care not available in the formal network (i.e., socialization, service needs) as specified in participant plans of care.
Monitors participant condition and provision of service pertaining to plans of care. Adjust plan as determined through reassessment or normal monitoring. Maintain communication with participant’s family and physician.
Maintains participant files and a tracking system for participants applying for and receiving entitlement services, and other pertinent program records.
Seeks clinical consultation from supervisory staff as needed to assure high quality plans of care.
Manages participant’s eligibility process for financial assistance, including communications with DHHS Eligibility Specialist and preparing and tracking necessary applications.
Keeps current on gerontological social work trends and skills needed to be successful.
Adjust to changing guidelines regarding the MI Choice Waiver contract, etc.
