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The Information Center, Inc.•Taylor, MI

About The Position

Under the supervision of the CMD Manager, use person-centered principles to assess the medical, functional, psychological, financial, and environmental needs of MI Choice Medicaid Waiver participants. Work with participants, family members, and caregivers to develop person-centered plans, support participants in managing their care needs, and provide ongoing monitoring and reassessment.

Requirements

Maintain appropriate state licensure or certification and complete all licensure requirements.
Maintain appropriate professional ethics and boundaries.

Responsibilities

Complete in-home assessments to identify needs and service preferences, including the frequency and duration of social services required under the care plan.
Gather and integrate information from participants, family members, guardians, Adult Foster Care providers, medical and treatment histories, needs surveys, and assessments from other disciplines.
Use motivational interviewing techniques to assess and articulate participants’ motivation to address needs identified during assessments.
Understand disease progression and collaborate with outside entities such as hospice, skilled care, and community mental health services.
Identify potential health care issues, including nutrition and hydration, continence, and physical conditions.
Collaborate with physicians, LPNs, and other outside medical staff to determine effective treatment for participants.
Maintain a caseload and complete assessments, documentation, and reporting by due dates.
Work with the Community Resources Department to provide participants, family members, and guardians with accurate information about services, supports, and community resources.
Develop comprehensive and integrated Individualized Plans of Service with participants and other supports, consistent with person-centered planning, self-determination, and current Medicaid guidelines.
Conduct in-home reassessment visits as part of an RN/SW team, completing social work portions in consultation with the RN team member.
Reassess participants’ service needs and preferences as needed and at least every three months.
Document all service activities and contacts concerning participants in accordance with contract requirements.
Connect participants with community services and supports based on needs and preferences in their Individualized Plans of Service.
Work with family members and volunteer caregivers to maximize informal support systems.
Participate in scheduled clinical supervision, case consultations, department meetings, and staff development sessions.
Meet productivity standards and comply with program standards and guidelines; complete documentation within expected timeframes.
Participate in Waiver outreach and enrollment activities.
Maintain appropriate state licensure or certification and fulfill licensure requirements.
Maintain professional ethics and boundaries.
Follow agency and department policies and procedures.
Perform other duties as assigned.