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Care Coordinator
2 months ago
This is a full-time community-based position requiring frequent travel within the assigned territory in DE. The incumbent will travel to members' homes, nursing facilities, and other community-based settings for individuals enrolled in DSHP Plus LTSS.
Key Responsibilities- Conduct face-to-face needs assessments with members and their caregivers, followed by telephonic contact to ensure continuity of care.
- Assess, plan, coordinate, implement, and evaluate care for eligible members with chronic and complex healthcare needs.
- Coordinate care across the continuum of services, including physical, behavioral, long-term services and supports (LTSS), social, and psychosocial needs.
- Facilitate authorization, coordination, continuity, and appropriateness of care and services in community or HCBS settings.
- Develop and implement plans of care in conjunction with members or caregivers to identify services that meet their specific needs and goals.
- Collaborate with the member's healthcare and service delivery team to coordinate care needs and community resources.
- Document all case management services and interventions in the electronic health record.
- Bachelor's degree in Social Work or a related field, or a registered nurse with 2 years of experience in long-term care, home health, hospice, public health, or assisted living.
- 3 years of experience in case management of the aged, including management of behavioral health conditions, or persons with physical or developmental disabilities, or HIV/AIDS population.
- One year of home clinical or case management experience.
- Certified Case Manager (CCM) or Licensed Bachelors Social Worker (LBSW).
- Working flexible hours to meet member needs.
- Proficiency in PC-based word processing and database documentation.
- Reliable transportation for daily travel within the assigned territory.
English
Travel Requirement25% - 50%
Work EnvironmentWorks from home, with occasional travel to various work sites or from site-to-site.