Care Coordinator, BSW- CCSP

About the role

Care Coordinator, BSW – Fulton & Dekalb Visiting Nurse Health System (Visiting Nurse) is hiring for a dynamic Social Worker, BSW, who provides case management activities necessary to meet the needs of clients assigned to the consolidated care team.

Responsibilities

• Arranges both CCSP and non-CCSP community-based services in collaboration with the RN care coordinator, the client and family members.
• Carefully coordinates Medicaid application team to assure that the CCSP is accessible to functionally impaired Medicaid eligible persons.
• Arranges emergency services as applicable.
• Carefully coordinates with the lead agency or DHR as needed to assure that all components of CCSP are responsive to the needs of the client.
• Serves as the transition point and link between the assessment process and the effective delivery of direct services.
• Develops appropriate care plans in consultation with the client, client’s family, and service providers.
• Effectively implements the care plan and brokers the CCSP services.
• Complies with standards of promptness set forth by DHR policy regarding specific activities:
• Completes assessments within 5 days of referral.
• Follows up on direct services ordered within 10 days.
• Reviews care plan within the first 60 days of LOC date.
• Reviews care plans every 4 months at a minimum or more often as needed.
• Provides updated data monthly at a minimum for the purpose of reporting requirements.
• Completes a reassessment annually or refers to team RN for reassessment to avoid lapse of MD orders.
• Documents all care management activity and service-related information.
• Ensures that documentation is consistent with the format required by departmental cognitive standards (i.e., progress notes reflect care plans).
• Maintains confidential case records on all CCSP clients.
• Demonstrates the ability to follow through in a thorough and timely manner on tasks assigned by management team and requests made by patients/families, referral sources, and community.
• Documents appropriate follow up on client needs whether related to CCSP services or other community resource needs.
• Financially limits amount and frequency of service to assure that costs do not exceed the limitations established by the Division of Aging Services and the Department of Community Health.
• Authorizes payment for service providers within the DHR standards of promptness following the service date.
• Legally requests redetermination of the client’s level of care prior to its expirations.
• Demonstrates knowledge and understanding of CCSP manual, Medicare and Medicaid regulations, physicians’ orders and the standards of care.
• Demonstrates knowledge of and adheres to the policies and procedures of Visiting Nurse Health System.
• Maintains current knowledge of community resources to ensure that the care plan is realistic and to coordinate and/or arrange services to clients.
• Maintains current knowledge about the service standards for each CCSP service.
• Actively participates in interdisciplinary conferences to coordinate care, problem-solve, and exchange views and information.
• Documents case conference activities and follow up.
• Complies with standards of promptness set forth by DCH and VNHS policy regarding specific activities:
• Do not provide a full list as it was not specified in the job posting.

Qualifications

• Bachelor’s degree in Social Work, Sociology, Psychology, or a related field.
• Two years of experience in case management in a health care field.
• Two years of experience with Medicare, Medicaid and other funding source.

Skills

• Strong communication skills.
• Ability to manage multiple tasks and prioritize responsibilities.
• Knowledge of community resources and services.
• Proficiency in Microsoft Office Suite.

Benefits

• Medical, Dental, and Vision insurance.
• Employee Assistance Program.
• Employee Discount.
• Flexible Schedule.
• Flexible Spending Account (FSA).
• Health Savings Account (HSA).
• Life insurance.
• Paid Time Off (PTO) and 9 holidays.
• 403b w/company match.

Pay

This position pay range is $40,000 - 60,000.

Schedule

Full-time, Monday- Friday.