This field/remote based role in LA County provides long-term care management to frail, economically disadvantaged, culturally diverse older adults, disabled adults and caregivers in order to help them remain safely at home and to prevent premature institutionalization. The role involves assessing new clients for the MSSP program, certifying clients as nursing home eligible, and conducting assessments and reassessments to identify medical, physical, and psychological needs. A key responsibility is ensuring client needs are met through a written care plan approved by the program supervisor and discussed with the client or representative. The role also includes providing ongoing health education to non-clinical staff, presenting cases in weekly team conferences, and discussing complex health care issues for teaching purposes. Collaboration with physicians, home health agencies, community services, family members, hospital discharge planners, and other professionals is essential to ensure appropriate services and a safe living environment below the cost of a skilled nursing facility. Maintaining monthly and other clinical documentation in a timely manner, along with accurate purchase of service records, is crucial. The position also involves developing and implementing care plans, maintaining census, providing customer service through outreach activities, participating in Quality Assurance chart reviews and other audits, and assisting in training new employees. Continuous learning is emphasized, including staying current on Medicare and Medi-Cal policies, relevant legislation, and community resources, as well as actively participating in supervision and professional development.
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
Job Type
Full-time
Career Level
Mid Level