Geriatric Care Manager SCO CCA

Central Boston Elder Services Inc•Boston, MA

1d•$50,103 - $67,526•Hybrid

About The Position

The Geriatric Support Services Coordinator (GSSC) is the care manager assigned to work with SCO enrollees and is a member of the Primary Care Team (PCT). The GSSC is responsible for coordinating and providing community social services to SCO enrollees – who are the frailest elders – by the SCO’s policies, procedures, and practices. The GSSC assists the PCT or PCP in promoting the SCO enrollee’s independent functioning in the most appropriate, least restrictive setting. GSSCs are expected to be on-site at B.U. Geriatrics two days per week.

Requirements

Have the knowledge and skills necessary to work successfully in an interdisciplinary team and to provide or arrange community long-term care.
Have the ability to assess clients and their needs and knowledge of the community-based service network.
Possess excellent interpersonal and problem-solving skills
Have the ability to work with a diverse population

Nice To Haves

Access to car desirable

Responsibilities

As a member of the Primary Care Team (PCT), participate in Initial and Ongoing Assessments of the health and functional status of enrollees, including determining appropriateness for institutional long-term care services and developing community-based care plans and related service packages necessary to improve or maintain an enrollee’s health and functioning.
Arrange, coordinate, and authorize the provision of appropriate long-term care and social support services for enrollees (with the agreement of the PCT and by requirements set forth by the SCO). These may include but not be limited to: ADL and IADL assistance; Housing; Home-delivered Meals; and Transportation.
Monitor the appropriate provision and functional outcomes of community long-term care services that have been authorized by the PCT.
Track enrollee transfers from one setting to another (for example, hospital to home or nursing home to adult day health) and adjust service plan as deemed appropriate by the PCT and by requirements set forth by the SCO.
When an enrollee resides outside of the catchment area, coordinate information with local ASAP outside of Boston; otherwise visit enrollee in Boston neighborhoods not served by CBES
Participate in case conferences with the PCP, Nurse Care Managers, and representatives from other disciplines to identify the optimal plan of care for SCO members.
Participate in all required training by the SCO and CBES
Respond on time to enrollee service requests
In collaboration with the PCT, the enrollee, the enrollee’s designated representative, and providers of community-based services in determining appropriate discharge plans after admission to an institution
Prepare documentation for enrollee files and ensure appropriate time entries and updates of enrollee information available in the Centralized Enrollee Record (CER).
Have a working knowledge of SAMS, Altruist (CCA database), and Epic (BUGS database) to enter and retrieve data.
Perform all services by state and federal law and written SCO management protocols.
Attend and participate in agency and departmental meetings and trainings as required
Other duties as assigned.