Care Coordinator-MyCare

DIRECTION HOME AKRON CANTON AREA AG•Green, OH

21h•$64,700 - $79,200•Onsite

About The Position

Provides care coordination for managed care consumers in the MyCare Ohio (fully delegated care coordination) waiver program. Delivers person-centered care coordination and management for MyCare Ohio enrollees through a collaborative, team-based approach that addresses medical and social needs to improve overall health outcomes.

Requirements

Experience in home health care, medical social work or geriatrics
Registered Nurse in the State of Ohio or Licensed Social Worker in the State of Ohio
At least one year of experience working with persons with disabilities/chronic conditions and LTSS

Nice To Haves

Previous Care Management experience
One year of experience in home care, geriatrics, behavioral health, or long-term care.
Knowledge of chronic disease management.

Responsibilities

Evaluate assessment data to determine ongoing program eligibility, care needs, and service options.
Conduct initial and ongoing Waiver Service Needs Assessments using ODM approved tools and care management to determine ongoing program eligibility, care needs, and service options.
Complete home visits and phone contacts according to assigned tier to ensure health, safety, service satisfaction and provide education to members.
Complete significant change event assessments that require a medication reconciliation and/or comprehensive assessment within required timeframes.
Collaborate with the Department of Job and Family Service to establish and/or maintain Medicaid eligibility.
Assist with telephonic after-hours coverage.
Complete all required documentation within 3 business days of that activity.
Provide education about Waiver services options, self-directed care, and appeal rights.
Link members with network providers as well as Medicare services to ensure coordination of care.
Provide education about reporting abuse, neglect, and exploitation.
Manage transitions of care by attending discharge planning meetings and ensure timely provision of supports while utilizing all benefits available to member such as the HOME Choice Program.
Offer and link members, as appropriate, to health education, disease management and wellness/prevention coaching.
Develop, implement and update the person-centered care plan according to the program contract following receipt of the request for Waiver services for all members, including direct Care Coordination interventions to address a consumer’s unstable conditions. The person-centered care plan must include disaster preparedness/back up plans and scope of service to address a member’s unstable conditions.
Develop and lead the Interdisciplinary Care Team meetings.
Advocate on behalf of members and/or caregiver/family and assist individuals in securing appropriate services and care settings.
Disenroll all ineligible members from the program.
Respond to questions, problems, or complaints from members, providers, and advocates.
Apply judgments and perform clinical practice based upon education, experience and professional practice standards.
Complete required training topics including such topics as health equity, implicit bias, disability competency, and incident reporting.