Nurse Case Manager

Tri-County Aging Consortium•Lansing, MI

2d•Onsite

About The Position

Works with the elderly and the disabled who are at-risk of entering a nursing home by exploring their options and alternatives to institutional care. The Supports Coordinator Team, consisting of a Social Worker and RN, complete comprehensive assessments of participants, with a strong emphasis on Person Centered Planning and participant direction. Many of the specific duties listed below are mandated by the Michigan Department of Health & Human Services (MDHHS), Bureau of Aging, Community Living, and Supports (ACLS Bureau) Care Management Performance Standards.

Requirements

Must be a Registered Nurse.
Must be a Registered Nurse (RN) with a current Michigan Nursing License, in good standing.
One year of experience working with the elderly and/or disabled is required.
Must possess a current Michigan driver's license in good standing (less than 4 points preferred).

Nice To Haves

Computer skills sufficient to learn specific departmental software programs.
Ability to maintain confidential information regarding all aspects of participant, volunteer, employee, and agency information.
Ability to work independently or as part of a team.
Ability to communicate effectively and establish good relationships with staff, participants, volunteers, and vendors.
Ability to represent the Agency in a professional manner.
Must be able to adjust priorities to meet deadlines in a timely manner.
Ability to meet department standards regarding job knowledge, participant focus, initiative, productivity, communication, teamwork, and attendance.
Knowledge of community services and resources.
Must possess strong assessment skills.

Responsibilities

Assists participants with securing Medicaid eligibility for Waiver services and monitoring for ongoing program eligibility.
Using the principles of Person-Centered Planning, the Care Management Team develops care plans with each participant, addressing and honoring the individual's specific needs and desires.
Conducts assessments as a member of a professional team. Assessments include an evaluation of the consumer's physical and mental health, functional capabilities and limitations, informal and formal support systems, physical environment, and financial resources.
Completes periodic reassessments as a team or individual Supports Coordinator.
Arranges, coordinates, and monitors the services according to the person-centered plan, including those covered through the Medicaid Waiver and Bureau of Aging, Community Living, and Supports (ACLS Bureau).
Monitor the cost of Medicaid Waiver services and other formal services to maximize resources and stay within program parameters and goals.
Maintains accurate files with all the mandatory documents including ACLS Bureau and Medicaid Waiver documentation. Includes the use of a computer to enter information into program software and established database system.
Adhere to agency and program standards, and ACLS Bureau and MDHHS Supports Coordinator Performance Criteria.
Participate in Quality Assurance activities.
Completes follow-up of all services arranged as determined in the person-centered care plan and adjusts as needed.
Provides advocacy on behalf of participants to secure services and benefits to which they are entitled and promotes participant freedom of choice.
Maintains shared caseload in conjunction with the RN or Social Work Supports Coordinator.
As part of the teamwork practice, back-up is provided to the other Supports Coordinator.
Updates knowledge pertinent to the provision of services to the elderly and persons with disabilities through attendance at agency and community meetings and continuing education opportunities.
Establish and maintain working relationships with physicians, hospital discharge staff, nursing home staff, home health and other service providers.
Covers 24-hour on-call services as scheduled.