Responsible for determining and monitoring the appropriate long term care needs of financially eligible clients over the age of 65 who are requesting or receiving assistance through home and community based services. Responsible for coordinating home and community based services to eligible participants by identifying their strengths and needs and incorporating formal and informal supports through a participant-centered approach to service planning and delivery. Responsible for completion of a comprehensive assessment to identify client strengths and needs. Responsible for providing participants with choices for safe independent living options and consumer-directed services that are cost efficient. #INDLP ESSENTIAL JOB FUNCTIONS: 1. Must report to work as scheduled on a regular and reliable basis. 2. Successfully complete all required pre-service orientation and training. 3. Must insure confidentiality of all client information and act in accordance with HIPAA regulations. 4. Ability to understand and comply with various laws, rules, regulations, policies and guidelines as they pertain to both ENOA and ENHSA. 5. Ability to communicate clearly, both orally and in writing and be able to establish effective working relationships with many different people, ranging from directors, coordinators, professionals, community representatives, support staff and the general public. 6. Be a strong team player with positive attitude toward working with staff and with clients and their formal and informal support systems. 7. Must have good computer skills with general knowledge of Microsoft office and have the ability to learn other computer systems. 8. Work with established standards for service coordination and employee’s professional discipline. 9. Basic knowledge of applicable state and federal laws, policies and regulations as they relate to the Nebraska Medicaid Program. 10. Knowledge of medical and psychiatric diagnoses, prognoses, needs, and expected outcome goals. 11. Ability to establish positive relationships, promote client/family autonomy while using a participant-centered approach to the service coordination process. 12. Assessment: A comprehensive assessment is the vital first step in the service coordination process. This assessment is the process of systematically and comprehensively identifying the strengths and limitations that influence the participant/client’s functional capacity. The assessment process includes a face to face interview with participant/client in their home environment, observations, and collateral contacts to confirm the Nursing Facility level of care determination and proceeds accordingly. The service coordinator uses a participant centered process in which the participant/client identifies strengths, needs, priorities, resources, and barriers. Each participant/client needs to be reassessed at least annually and upon any major biopsycho-social changes that influence their functional ability and safety. 13. Planning: The plan of services and supports is a collaborative, written document that is prepared with the participant/client and services coordinator. It is based on the findings from the comprehensive assessment, collateral data and the participant’s/client’s preferences. The plan of services and supports document includes: problem statements converted to measurable outcome goals, strengths, intervention/service objectives, units of service (formal and informal), timeframes and providers/contacts. The Service Coordinator and the participant decide on the level of services coordination and determine the role of the Services Coordinator and the participant in the plan implementation. 14. Implementation: The Services Coordinator and the participant identify formal providers and informal supports with focus upon participant preference and cost effectiveness. 15. Coordination: Services and care arrangements require a Service Coordinator to be the broker of high quality and cost effective services. A Service Coordinator must develop and maintain rapport and communications with the participant/family and caregiver/s so that important information regarding delivery of services and products impacting on the goals and outcome of the plan can be disclosed. Maintaining professional rapport and communication with the members of the team is essential so the plan can be discussed objectively, problems identified, and adjustments made to the plan as needed. The Service Coordinator for the participant is the “team leader” for said participant and initiates communication with other disciplines as needed for appropriate planning (e.g. joint assessments, care planning meetings, external professionals). 16. Monitoring: Careful follow-up that tracks whether or not the service was provided as requested and if it was satisfying; monitoring must occur in a timely manner via direct and telephone contact. Maintain regular communication with all providers delivering care, services, and products to the participant for quality assurance purposes. Ascertain that the outcomes of the plan are appropriate, understood, documented, and being met. Advise the providers of adjustments or revisions to be made in the plan. 17. Evaluation: Determining if the outcome goals and service objectives in the plan of services and supports produce beneficial results to the client and agency. This may include gathering statistical information to evaluate both client level outcomes and service utilization outcomes. 18. Advocacy: The Service Coordinator provides the client with information and training that promotes self-sufficiency. Advocacy is a process that occurs throughout the service coordination process and is an essential element to ensure participant centered care and empowerment. 19. Must have a valid driver’s license, reliable vehicle and state required car insurance.
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Job Type
Full-time
Career Level
Entry Level