Care Coordinator, BSW- CCSP

Visiting Nurse Health System•Atlanta, GA

About The Position

Visiting Nurse Health System is hiring a BSW Care Coordinator to serve members in various parts of Georgia. The role provides case management activities to meet the needs of clients assigned to the consolidated care team. The coordinator develops individualized care management plans, implements them by brokering and coordinating services, and monitors and evaluates clinical outcomes to ensure professional, comprehensive, and cost-effective care. The position coordinates CCSP and non-CCSP community-based services, working with the RN care coordinator, clients, families, Medicaid application teams, lead agencies, and DHR. It includes assessing clients, arranging services, implementing and reviewing care plans, maintaining complete confidential records, managing service authorizations within cost limits, and following applicable regulatory requirements and organizational policies. The coordinator also monitors service delivery, maintains knowledge of community resources and CCSP service standards, and participates in interdisciplinary conferences. The position is PRN, scheduled Monday through Friday, with day-shift hours. Compensation is paid per visit.

Requirements

Bachelor's degree in Social Work, Sociology, Psychology, or a related field.
Two years of case management experience 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 people.
Arrange emergency services when applicable.
Coordinate with the lead agency or DHR as needed to ensure CCSP components respond to client needs.
Act as the transition point between assessment and delivery of direct services.
Develop care plans in consultation with clients, their families, and service providers.
Implement care plans and broker CCSP services.
Complete assessments within five days of referral, follow up on direct services ordered within ten days, and review the care plan within the first 60 days of the level-of-care date.
Review care plans at least every four months or more often as needed, provide monthly updated data for reporting, and complete or arrange annual reassessments to avoid a lapse in physician orders.
Document care management activities, service-related information, client needs, and follow-up; maintain confidential case records.
Complete assigned tasks and requests from management, patients and families, referral sources, and the community thoroughly and promptly.
Limit the amount and frequency of services to stay within cost limitations established by the Division of Aging Services and Department of Community Health.
Authorize payment for service providers within DHR standards of promptness following the service date.
Request redetermination of a client's level of care before it expires.
Follow CCSP, Medicare, and Medicaid regulations, physicians' orders, standards of care, and Visiting Nurse Health System policies and procedures.
Maintain current knowledge of community resources and CCSP service standards.
Monitor service delivery and follow up to determine whether services are provided appropriately and effectively meet client needs.
Participate in interdisciplinary conferences to coordinate care, solve problems, and exchange information; document conference activities and follow-up.