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JOB SUMMARY
This job serves as the single point of contact for members to coordinate all of the member’s care needs across the various service delivery systems and community supports. This is a full-time community-based position requiring frequent travel within the assigned territory in DE. A significant portion of this role involves working directly with members in their homes and also requires providing case management services within nursing facility settings. The incumbent will travel to members’ homes, nursing facilities, and other community-based settings for individuals enrolled in DSHP Plus LTSS and DSNP.
ESSENTIAL RESPONSIBILITIES
Conduct regular in-home and nursing facility visits: Travel to members’ homes, nursing facilities, and other community-based settings to complete face to face needs assessments with subsequent telephonic contact with the member in accordance with state and national guidelines, policies, procedures, and protocols. This includes actively working within the nursing facility environment and participating in NF care plan conferences to ensure member needs are met.
Assess, plan, coordinate, implement and evaluate care for eligible members with chronic and complex health care, social service and custodial needs in a nursing facility or home and community-based care setting.
Coordinate care across the continuum of services and assisting members physical, behavioral, long term services and supports (LTSS), social, and psychosocial needs in the safest, least restrictive way possible while considering the most cost-effective way to address those needs. This includes ensuring appropriate care transitions between home, community, and community-based care settings.
Authorize LTSS services based upon completion of a comprehensive needs assessment. Coordinate HCBS services, Medicaid and DSNP benefits and assess appropriateness of care and services in community.
Facilitate transitions to alternate care settings such as hospital to home, nursing facility to community setting using an integrated care team to address the member’s specific needs.
Educate members or caregivers regarding health care needs, available benefits, resources and services including available options for long term care community or facility-based service delivery.
Provide education, resources, and assistance to help members achieve goals as outlined in their plan of care and to overcome obstacles to achieving optimal care in the least restrictive environment.
Develop individualized care plans in conjunction with members or caregivers to identify services to meet the member’s specific needs, and goals.
Identify resources needed for a fully integrated care coordination approach including facilitating referrals to special programs such as Disease/Chronic Condition Management, Behavioral Health, and Complex Case Management.
Collaborate with the member's health care and service delivery team including the physical, behavioral health providers, ICT, and discharge planners, to coordinate the care needs and community resources for the member to maintain the member in the least restrictive safe environment possible.
Assist members in developing, implementing and amending a back-up plan for gaps in provider coverage.
Ensure approved support services are being provided as outlined in the plan of care.
Evaluate the effectiveness of the service plan and making appropriate revisions as needed in accordance with per policy & procedures and state contractual requirements.
Assist members in overcoming obstacles to optimal care through connection with community resources, including communicating with providers and formulating an appropriate action plan.
Document all case management services and intervention in the electronic health record.
Adhere to all company, State and Federal requirements related to privacy practices, HIPAA, and quality performance standards.
Perform other duties as assigned/requested.
QUALIFICATIONS
Required
Bachelor's degree in Social Work or in health, human, or education services and 3 years of experience in long-term care, home health, hospice, public health, or assisted living OR
Master’s degree in Social Work or in health, human, or education services and 1 year of experience in long-term care, home health, hospice, public health, or assisted living OR
Current State RN or LPN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC) and 2 years of experience in long-term care, home health, hospice, public health, or assisted living OR
A high school degree or equivalent and three years of qualifying experience with case management of the aged, including management of behavioral health conditions, or persons with physical or developmental disabilities, or HIV/AIDS population.
Substitutions
None
Preferred
One year in home clinical or case management experience
Certified Case Manager (CCM)
Licensed Bachelors Social Worker (LBSW)
Licensed Masters Social Worker (LMSW)
Licensed Clinical Social Worker (LCSW)
Experience working with HIV/AIDS population
Experience working with behavioral health population
Experience working with developmental disabilities population
Medicare and Medicaid experience
Managed care experience
SKILLS
Working flexible hours to meet member’s needs
Proficiency in PC-based word processing and database documentation (Word, Excel, Internet, Outlook)
Reliable transportation daily to be able to travel within assigned territory
Ability to meet regulatory deadlines.
Has a dedicated home work space used only for business purposes and is able to comply with all telecommuter policies.
Experience in geriatric special needs, behavioral health, home health
Understanding of the importance of cultural competency in addressing targeted populations.
Experience with electronic documentation system(s)
Experience with cost neutrality and budgeting
Language (Other than English):
None
Travel Requirement:
25% - 50%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Position Type
Works From Home
Teaches / trains others regularly
Occasionally
Travel regularly from the office to various work sites or from site-to-site
Occasionally
Works primarily out-of-the office selling products/services (sales employees)
Never
Physical work site required
Yes
Lifting: up to 10 pounds
Constantly
Lifting: 10 to 25 pounds
Occasionally
Lifting: 25 to 50 pounds
Rarely
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.
Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
Pay Range Minimum:
$72,700.00Pay Range Maximum:
$116,600.00Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.
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