Caseworker 2 - PASRR Specialist - 1667

CENTRAL COUNTIES CENTER FOR MENTAL•Belton, TX

13d•$22•Hybrid

About The Position

Serves as a member of the centralized team that monitors and responds to all Preadmission Screening and Resident Review (PASRR) alerts for individuals seeking admission to or residing in a nursing facility. Completes or coordinates required evaluations, record reviews, interviews, notices, team meetings, referrals, and electronic documentation within current Texas Health and Human Services Commission (HHSC) requirements and agency standards. For individuals who are PASRR positive for intellectual or developmental disability (ID/DD), serves as the assigned Habilitation Coordinator and coordinates person-centered planning, specialized-service monitoring, and community-living activities required by HHSC. For individuals who are PASRR positive for mental illness (MI), maintains PASRR oversight and required follow-up. When MI specialized services are accepted, refers the individual to the designated Behavioral Health clinic for required clinical assessment, treatment or recovery planning, and service delivery while continuing PASRR compliance and coordination functions. Works closely with individuals, legally authorized representatives, nursing facilities, agency programs, and internal and external providers. Routine travel throughout the five-county service area is required. This is a community-based position requiring services to be provided primarily outside a Central Counties Services office. The employee will be assigned a CCS worksite as their designated home base. Community-based work does not constitute or automatically authorize remote work. During the first six months in the position, the employee will work from the assigned CCS worksite when not performing duties in the community. After six months, remote-work eligibility may be considered based on operational needs, job performance, documentation compliance, and Center policy but is not guaranteed. The employee must report to the assigned worksite for required meetings, training, supervision, events, or other activities, and the supervisor may establish required in-office days or hours based on job-related or operational needs.

Requirements

Bachelor's degree in Psychology, Social Work, or a related social services field.
Minimum of one year of experience working with individuals with IDD or DD.
Meets current HHSC qualifications for staff conducting PASRR evaluations or resident reviews and any applicable behavioral-health professional requirements.
Completes required PASRR, habilitation coordination, person-centered planning, and agency training and demonstrates competency within required timeframes.
Knowledge of applicable PASRR, habilitation coordination, person-centered planning, and HHSC requirements.
Ability to assess individual needs and risks, exercise sound judgment, and coordinate appropriate services and referrals.
Ability to conduct effective person-centered interviews and facilitate interdisciplinary and service-planning meetings.
Ability to complete required evaluation, planning, monitoring, and progress documentation accurately within agency and HHSC timeframes.
Ability to proficiently use the agency electronic health record, state-designated PASRR systems, and standard office software, including Microsoft Word and Excel.
Ability to communicate effectively, respond to consumer crises in a timely and appropriate manner, and manage challenging or potentially aggressive behavior consistent with required training and Center policy.
Ability to speak to groups regarding services.
May be required to provide services in facilities that require proof of vaccination.
Sit, stand, and walk for extended periods of time.
See, hear, and communicate effectively to perform job duties.
Use a computer, telephone, and standard office equipment for prolonged periods.
Perform repetitive tasks such as typing, filing, and data entry.
Lift and/or move up to 15 pounds.
Interact frequently with consumers, staff, and the public in a professional and customer focused manner.
Respond appropriately to challenging or unpredictable situations, including safely de-escalating and managing interactions with individuals who may exhibit verbally or physically escalated behavior, in accordance with training and Center policies.
Ability to perform the essential functions of the position safely and effectively, including maintaining professionalism, sound judgment, appropriate interpersonal interactions, concentration, and the ability to respond appropriately in stressful or crisis situations, with or without reasonable accommodation.
Work in an environment with frequent interruptions and changing priorities.
Perform the essential functions of the position, with or without reasonable accommodation, in accordance with the Americans with Disabilities Act (ADA).
Must possess and maintain a valid driver's license, an acceptable driving record, and access to a reliable personal vehicle.
Because availability of a Center vehicle cannot be guaranteed, the employee is required to use their personal vehicle for work-related travel when a Center vehicle is not available.
Mileage for authorized use of a personal vehicle will be reimbursed in accordance with Center policy and established procedures.
Occasional travel outside the catchment area may be required for training or cases involving extenuating circumstances.

Nice To Haves

Central Counties Services incorporates principles of trauma-informed care, including cultural sensitivity, in all areas of service delivery. Employees are responsible for learning and implementing trauma-informed practices within the scope of their work.

Responsibilities

Monitors, receives, reviews, assigns, and responds to PASRR alerts and referrals at assigned nursing facilities and as part of assigned rotating weekend and holiday coverage.
Reviews the initial screening, admission category, existing PASRR history, diagnostic records, Medicaid information, and other available documentation to identify the required response and applicable deadlines.
Initiates required contact with the individual and appropriate collateral sources and completes the PASRR evaluation or resident review within current HHSC timeframes.
Interviews the individual, legally authorized representative, nursing-facility staff, referring entity, family members, and other knowledgeable persons; obtains or reviews relevant medical, psychiatric, diagnostic, educational, and service records.
Determines and documents whether the individual is PASRR positive or negative for ID/DD, MI, or both, and completes required notices, referrals, fair-hearing information, and electronic entries.
Participates in the initial interdisciplinary team meeting, communicates evaluation results and recommended specialized services, and addresses community-living information when required.
Completes required evaluation packets and enters diagnostic, financial, insurance, and service information in the agency electronic health record and state-designated PASRR system.
Coordinates with the PASRR Supervisor when extenuating circumstances may require an extension, maintains current status information, and supports evaluations associated with nursing-facility ownership changes or other special circumstances.
Serves as the Habilitation Coordinator for eligible individuals whose PASRR evaluation or resident review is positive for ID/DD.
Reviews the PASRR evaluation, community-living information, nursing-facility care plan, diagnostic information, assessments, and available service history before the initial planning meeting.
Completes required initial and annual habilitative assessments and maintains a current person-centered individual profile and habilitation service plan.
Convenes and facilitates initial, quarterly, annual, and update service-planning meetings in accordance with current HHSC requirements.
Coordinates the habilitation service plan with the nursing-facility plan of care and revises the plan when needs, outcomes, risks, or services change.
Meets with the individual at the frequency required by HHSC and Center policy and documents service delivery, progress, satisfaction, risks, and the effectiveness of specialized services.
Coordinates and monitors agreed-upon IDD habilitative, nursing-facility, and, when applicable, MI specialized services; follows up on delayed, interrupted, or ineffective services.
Presents and documents community-living options at required intervals, identifies and addresses barriers, offers required educational opportunities, and initiates transition or relocation referrals when the individual expresses interest in community living.
Completes required refusal documentation when an individual declines habilitation coordination and continues all assessment, community-living, and annual-review activities required by HHSC.
Completes required state-system entries and submits service-planning documentation for supervisory review within agency and HHSC timeframes.
Maintains PASRR responsibility for individuals who are positive for MI and decline specialized services.
Completes current refusal documentation, obtains required signatures, provides required copies, and ensures the refusal is accurately reflected in the agency record and state-designated PASRR system.
Conducts and documents required follow-up contacts at the frequency and for the duration established by HHSC, including efforts to engage the individual, explain available services, and determine whether the individual wishes to reconsider.
Tracks and participates in the annual interdisciplinary team meeting even when the individual continues to decline specialized services.
Refers the individual to the designated Behavioral Health clinic and coordinates required PASRR updates if the individual later elects to receive specialized services.
Refers the individual to the designated Behavioral Health clinic for completion of the state-required behavioral-health assessment, development and maintenance of the person-centered treatment or recovery plan, and delivery of agreed-upon MI specialized services.
Confirms that the clinic accepts the referral, identifies the assigned clinical provider, and transmits the evaluation, team decisions, and relevant supporting information through approved methods.
Retains responsibility for PASRR-specific oversight, including required interdisciplinary team participation, coordination with the nursing facility and clinic, state-system actions, and maintenance of PASRR documentation.
Obtains assessment, planning, and service recommendations from the clinic and coordinates any required local-authority update meeting and related PASRR documentation.
Tracks timely initiation of specialized services and maintains communication with the clinic regarding reassessment, service changes, refusals, changes in condition, eligibility changes, transfers, discharge, transition to the community, or death.
Participates in the annual interdisciplinary team meeting and obtains current clinical and progress information from the clinic for team review.
Coordinates with the Behavioral Health clinic throughout evaluation, service planning, service delivery, monitoring, and annual review for individuals who are positive for both ID/DD and MI.
Serves as the Habilitation Coordinator and leads overall coordination of IDD, MI, and nursing-facility specialized services through the interdisciplinary and service-planning process.
Ensures the Behavioral Health clinic receives meeting notices, provides required assessments and progress information, and participates when needed to support integrated person-centered planning.
Enters and final approves required service documentation in the agency electronic health record within Center policy and applicable HHSC timeframes.
Carries a work cell phone, checks email daily, and returns required calls and messages by 5:00 p.m. the next business day.
Notifies the supervisor when absent for the day or when starting work later than expected or assigned.
Follows Center on-call procedures on a rotating basis, monitors the state-designated PASRR system during assigned weekends and holidays, and responds to alerts within current HHSC timeframes.
Accurately records all hours worked using the Center-designated timekeeping and GPS-enabled location-verification system and complies with Center timekeeping, attendance, location-verification, and correction procedures.
Participates in the Random Moment Time Study as required, including completion of required training.
Performs other duties as assigned.