LTSS Service Coordinator Levl2

Houston, Texas, JOB SUMMARY The LTSS Service Coordinator Level 2 is responsible for overall management of non-HCBS (non-waiver) member’s case within the scope of licensure; provides supervision and direction to non-RN clinicians participating in the member’s case in accordance with applicable state law and contract; develops, monitors, evaluates, and revises the member’s care plan to meet the member’s needs, with the goal of optimizing member health care across the care continuum. Will perform a mix of face-to-face and telephonic assessments as mandated by state and federal regulations. JOB SPECIFICATIONS AND CORE COMPETENCIES Essential Functions Primary Responsibilities: Assess, plan, and implement care strategies that are individualized by member and directed toward the most appropriate, lease restrictive level of care. Identify and initiate referrals for social service programs, including financial, psychosocial, community and state supportive services. Manage the care plan throughout the continuum of care as a single point of contact. Communicate with all stakeholders the required health-related information to ensure quality coordinated care and services are provided expeditiously to all members. Advocate for patients and families as needed to ensure the patients needs and choices are fully represented and supported by the health care team. Perform telephonic and/or face-to-face clinical assessments for the identification, evaluation, coordination and management of members needs, including physical health, behavioral health, social services and long-term services and supports. Identify members for high-risk complications and coordinates care in conjunction with the member and the health care team. Manage members with chronic illnesses, co-morbidities, and/or disabilities, to insure cost effective and efficient utilization of health benefits.

Assists in meeting member needs by referring members to internal and external resources. Provide follow up with internal and external resources, providers, and state programs. Expect to spend about 50% of your time in the field visiting our members in their homes or in long-term care facilities. Youll need to be flexible, adaptable and, above all, patient in all types of situations. Marginal Functions Provide input and/or data to direct supervisor/manager related to any internal or external mandatory audit or reporting. Serve as mentor, subject matter expert or preceptor to new staff. Involved in process improvement initiatives. Assist in problem solving with providers, claims or service issues. Community Health Choices Core Competencies Customer Focus Reliability and Dependability Honest and Integrity Change Management Teamwork Impact/Influence + Strategic Vision People/Team Development Other duties as assigned. MINIMUM QUALIFICATIONS: Education/Specialized Training/Licensure: Requires a minimum of LVN, qualified IDD professional, or have an undergraduate or graduate degree in social work or a related field.

Registered Nurse, Nurse Practitioner, Licensed Social Worker, Physician Assistant preferred. Work Experience (Years and Area):Required: 4+ years of experience working within the community health setting in a health care role required. 1+ years of experience working with MS Word, Excel, and Outlook Experience in long-term care, home health, hospice, public health or assisted living Ability to travel in assigned region to visit Medicaid members in their homes and/or other settings, including community centers, hospitals, or provider. s offices. Preferred: 1+ years of experience working with Medicaid Waiver services. Experience with arranging community resources Field based work experience Experience with electronic charting Background in managing populations with complex medical or behavioral needs. 3-4 years working as a Service Coordinator, Case Manager, or similar role in a managed care setting Management Experience (Years and Area): N/A Software Proficiencies: Microsoft Office Clinical Documentation Platforms Reliable transportation with valid drivers license with good driving record reqired.

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