Care Coordinator, BSW- CCSP

Visiting Nurse Health System Inc•Atlanta, GA

18d•$40,000 - $60,000

About The Position

Visiting Nurse Health System is hiring a Care Coordinator, BSW, to serve members in North Fulton, Forsyth, and Hall County. The role provides case management to clients assigned to the consolidated care team, including developing individualized care management plans, brokering and coordinating services, and monitoring and evaluating clinical outcomes. The coordinator works to ensure services are professional, comprehensive, and cost-effective. The position coordinates CCSP and non-CCSP community-based services with the RN care coordinator, clients, families, service providers, and relevant agencies. It develops and implements care plans, arranges emergency and direct services, and helps ensure eligible clients can access CCSP. The coordinator completes assessments, follow-ups, reviews, and reassessments according to applicable policy timelines; maintains confidential case records and thorough documentation; monitors service delivery and care outcomes; and authorizes payments within established standards. The role also requires knowledge of community resources, CCSP requirements, Medicare and Medicaid regulations, physicians’ orders, standards of care, and Visiting Nurse policies and procedures. The Care Coordinator participates in interdisciplinary conferences and follows up on client needs, including needs involving other community resources.

Requirements

Bachelor’s degree in Social Work, Sociology, Psychology, or a related field.
Two years of experience in case management in a health care field.
Two years of experience with Medicare, Medicaid, and other funding sources.
Reliable transportation, a valid driver’s license, and proof of vehicle insurance.

Responsibilities

Arrange CCSP and non-CCSP community-based services in collaboration with the RN care coordinator, clients, and family members.
Coordinate with the Medicaid application team to help ensure CCSP access for functionally impaired Medicaid-eligible persons.
Arrange emergency services when applicable.
Coordinate with the lead agency or DHR as needed to ensure CCSP components respond to client needs.
Serve as the link between assessment and delivery of direct services.
Develop appropriate care plans in consultation with clients, families, and service providers.
Implement care plans and broker CCSP services.
Complete assessments within five days of referral, follow up on ordered direct services within ten days, and review care plans within the first 60 days of the level-of-care date, consistent with stated standards of promptness.
Review care plans at least every four months or more often as needed; provide monthly updated data for reporting; and complete or refer for annual reassessment to avoid a lapse in physicians’ orders.
Document care management activities and service-related information in the required format, maintain confidential CCSP case records, and document follow-up on client and community-resource needs.
Follow through thoroughly and promptly on management assignments and requests from patients, families, referral sources, and the community.
Limit service amounts and frequency so costs remain within Division of Aging Services and Department of Community Health limits.
Authorize payment to service providers within DHR standards of promptness following the service date.
Request redetermination of a client’s level of care before it expires.
Maintain current knowledge of community resources and CCSP service standards.
Monitor service delivery and follow up to determine whether services are appropriate and meet clients’ needs.
Participate in interdisciplinary conferences to coordinate care, resolve problems, and exchange information; document conference activities and follow-up.
Adhere to Visiting Nurse Health System policies and procedures and applicable DCH and VNHS standards of promptness.