Under the general supervision of the Manager, CMD, uses person centered principles to assess the medical, functional, psychological, financial, and environmental needs of MI Choice Medicaid Waiver participants. Works with the participant, family members and caregivers to develop a person centered plan, to assist and support the participant to manage their care needs and to provide ongoing monitoring and reassessment of participants.
RESPONSIBILITIES AND DUTIES
- Conduct in-home case management assessments to identify areas of need and service preferences, including determination of frequency and duration of services required under the care plan;
- Review participants medications and be able to assess or identity potential contraindications.
- Understand and assess disease progressions in order to collaborate with outside entities (e.g. hospice, skilled care, community mental health services).
- Understand and identify potential participant issues in health care including nutrition/hydration, continence, physical conditions, etc.
- Collaborate with physicians, LPN’s and other outside medical staff to determine effective treatment for the participant.
- Provide education and information to participants and their family members about the course of treatment in the home.
- Gather and integrate information from all available sources, including participant self-reports, reports from family members, guardians and Adult Foster Care providers, documented medical and treatment history, needs surveys, assessments from other disciplines, etc.;
- Utilize motivational interviewing techniques to assess and articulate the motivation of program participants to address specific needs identified during the assessment process;
- Work with Community Resources Department to provide participants, family members, and guardians with complete and accurate information regarding services, supports and other community resources available to meet needs identified during the assessment process;
- Assist with the development of comprehensive and integrated Individualized Plans of Service with participants and other supports (consistent with principles of Person-Centered Planning, Self-Determination and current Medicaid Guidelines);
- Conduct in-home reassessment visits collaboratively as an RN/SW Team, completing the RN portions of the reassessment in consultation with SW team member accordingly; Reassess the service needs and preferences of participants as needed, at a minimum every three months;
- Document all face-to-face service activity and phone contact pertaining to program participants, per contract requirements;
- Link participants to community services and supports based on the needs and preferences identified in their Individualized Plans of Service; Work with family members and other volunteer caregivers to maximize available informal support systems.
- Participate in regularly scheduled clinical supervision, case consultations, department meetings, and staff development sessions to make optimal use of resources for professional growth;
- Perform within acceptable standards of productivity ensuring compliance with all program standards and guidelines. Complete all documentation with expected timeframes;
- Maintain appropriate state licensure or certification and complete all requirements for licensure;
- Maintain appropriate professional ethics and boundaries;
- Abide by all TIC policies and procedures;
- This job description is not intended to be all inclusive, and employee will also perform other reasonable related duties as assigned by immediate supervisor and other management as required.
REQUIRED KNOWLEDGE, SKILLS, ABILITIES
Must be able to:
- work with all members of the community regardless of race, gender, age and cultural or ethnic background;
- work cooperatively with supervisors, colleagues and all agency staff;
- accept supervision and demonstrate an interest and willingness to continue his/her personal and professional growth and skill development;
- demonstrate a commitment to the welfare of the frail elderly and adults with disabilities the program serves and to the delivery of quality services;
- work in a community-based setting, independently with little direct supervision of daily duties;
- demonstrate strong computer skills – Word, Excel, Outlook;
- work as a positive and productive member of a team;
- represent the agency in a professional manner;
- appropriately handle crisis situations;
- Possess a valid Michigan Driver’s License and reliable transportation; have ability to travel within a geographic region (Out-Wayne County) utilizing own reliable transportation.
EDUCATION AND EXPERIENCE
- Requires a current license as a Registered Nurse in the State of Michigan.
- Prefer two years of experience in a hospital, home care, or community based setting.