Care Planning

· Develop, assess, and adjust as necessary the patient-centered care plan and promote desired outcomes along with monitoring the effectiveness of the plan and establishing measurable goals and outcomes.

· Conduct advanced care planning with client/member and others involved with client/member care as applicable.

· Conduct discharge planning following emergency room visits, hospitalizations, and nursing facility stays.

· Manage transitions between care settings including long-term care, community-based, and assisted living.

Client/Member Support

· Provide support/education to clients/members with complicated medical/psychosocial/behavioral/environmental issues.

· Conduct home visits and complete phone contacts with clients/members per required contact schedule.

· Empower, educate, and motivate client/member/caregiver within the scope of knowledge to gain access to health and community resources through education, outreach, home visits, mentoring, and referrals.

· Provide coaching, information, and support to empower clients/members to make ongoing independent lifestyle choices.

Coordination and Collaboration

· Collaborate with the interdisciplinary care team involved with client/member’s care, including the MCO Care Manager if applicable, to ensure all aspects of clients/members care are being addressed and monitored to promote quality, cost-effective outcomes.

· Report specific health and social information back to the integrated team to assist in development of care/service plan.

· If applicable, Participate in Interdisciplinary Care Conferences as scheduled by the care team, and client/caregivers.

Compliance and Documentation

· Adhere to COA confidentiality policy, Firewall Compliance, and HIPAA protocols as related to all client/member information/interactions.

· Adhere to all COA and Program policies and procedures.

· Complete incident reports as required and within the timeframe expectations.

· Utilize Service Guidelines when developing service plans/care plans with clients/members and caregivers to promote understanding of service rationale.

· Create and maintain client/member files.

· Meet compliance standards established for the program including but not limited to timely completion of annual reassessments, meet documentation timeframe, timely submission of incident reports, etc.

· Completes other duties as assigned.

Service Authorizations

· Authorize services in the most efficient means possible to meet identified client/member needs.

· Arrange and/or award referrals for needed services which includes services covered both within and outside of LTC programs and ensure that services are arranged in the most efficient manner to meet the member needs.

· Address provider issues related to client/member care and monitor service delivery.

· PASSPORT: Ohio licensed Social Worker, Licensed Practical Nurse (LPN), or Registered Nurse in good standing with the credentialing board.

· At least one year of experience working with persons with disabilities/chronic conditions and LTSS, preferably in Case Management.

· Prior experience completing electronic documentation a plus.

· A good working knowledge and understanding of issues related to the elderly population.

· Critical thinking skills and the ability to effectively use clinical judgment.

· Ability to learn in-person, through a written format, and virtually.

· Tolerant, empathetic, good interviewing capability.

· Knowledge of community resources within Southwestern Ohio.

· Good customer service skills.

· Ability to adapt to frequent change.

· Good oral and written communication skills.

· Good organizational and teamwork skills, including the ability to collaborate and solve problems in a self-directed team environment.

· Proficient computer skills including the Windows operating systems, MS Word, MS Excel, data entry and the ability to learn new software applications as needed.

· Respect the cultural, spiritual, racial, ethnic beliefs of others.

· A valid driver’s license and reliable transportation for travel within Butler, Clermont, Clinton, Hamilton and Warren Counties.

· Ability to travel within the state of Ohio for training.

To provide intake, assessment, and care management services to clients/members, which includes ongoing assessment for program eligibility, monitoring all aspects of care and client/member services (social and medical), ensuring needs of clients/members and caregivers are met through a collaborative process.