Job Posting Title LTSS Service Coordinator (Dekalb County, IN)

About the role

LTSS Service Coordinator. The candidate should reside in Dekalb, Steuben, Noble, or Whitley County, IN. This field‑based role enables associates to primarily operate in the field, traveling to client sites or designated locations as required, with occasional office attendance for meetings or training. Alternate locations may be considered if candidates reside within a commuting distance from an office. Per the hybrid/virtual work policy, candidates not within a reasonable commuting distance will not be considered unless an accommodation is granted as required by law. Elevance Health is a Fortune 25 health company dedicated to improving lives and communities and making healthcare simpler.

Responsibilities

• Conducting service coordination functions for a defined caseload of individuals in specialized programs.
• In collaboration with the person supported, facilitating the Person Centered Planning process that documents the member’s preferences, needs and self‑identified goals.
• Conducting assessments.
• Development of a comprehensive Person Centered Support Plan (PCSP) and backup plan.
• Interfacing with Medical Directors and participating in interdisciplinary care rounds to support development of a fully integrated care plan.
• Engaging the member’s circle of support and overall management of the individual’s physical health (PH)/behavioral health (BH)/LTSS needs, as required by applicable state law, contract, and federal requirements.
• Performing face‑to‑face program assessments (using various tools with pre‑defined questions) for identification.
• Applying motivational interviewing techniques for evaluations, coordination, and management of an individual’s waiver (such as LTSS/IDD), and BH or PH needs.
• Using tools and pre‑defined identification process to identify members with potential clinical health care needs (including, but not limited to, potential for high‑risk complications, gaps in care) and coordinating those members’ cases (serving as the single point of contact) with clinical healthcare management and the interdisciplinary team to provide care coordination support.
• Managing non‑clinical needs of members with chronic illnesses, co‑morbidities, and/or disabilities, to ensure cost‑effective and efficient utilization of long‑term services and supports.
• At the direction of the member, documenting their short and long‑term service and support goals in collaboration with the member’s chosen care team that may include caregivers, family, natural supports, service providers, and physicians.
• Identifying members that would benefit from an alternative level of service or other waiver programs.
• Serving as mentor, subject matter expert or preceptor for new staff, assisting in the formal training of associates, and possibly being involved in process improvement initiatives.
• Submitting utilization/authorization requests to utilization management with documentation supporting and aligning with the individual’s care plan.
• Reporting critical