Specialized Care Manager
About The Position
The Specialized Care Manager (SCM) is a member of the Money Follows the Person (MFP) team at the Agency on Aging of South Central Connecticut. The role coordinates successful transitions from nursing facilities and other institutional settings to community-based living. It provides assessment, care planning, service coordination, advocacy, and ongoing case management so participants have the resources and supports needed to live safely and independently in the community. The position works with consumers and their authorized representatives, healthcare providers, community agencies, family members, interdisciplinary team members, housing and transition coordinators, facility staff, and state partners. It includes discharge and transition planning, post-transition follow-up, quality monitoring, documentation, and participation in team meetings, trainings, and statewide initiatives. The schedule is Monday through Friday, 8:30 AM to 4:30 PM, with no evening, weekend, or holiday work. A hybrid schedule is available after successful completion of orientation and training.
Requirements
- Bachelor's degree in Social Work, Human Services, Nursing, Psychology, Gerontology, Public Health, or a related field.
- At least two years of experience in case management, care management, social services, discharge planning, healthcare, or long-term services and supports.
- Strong assessment, documentation, organizational, and problem-solving skills.
- Excellent communication and interpersonal skills.
- Ability to work independently and collaboratively within a multidisciplinary team.
- Valid driver's license and reliable transportation for community visits.
Nice To Haves
- Experience working with older adults and individuals with disabilities.
- Knowledge of Medicaid, waiver programs, and long-term services and supports.
- Familiarity with person-centered planning and community-based service coordination.
- Experience in care transitions, discharge planning, or community case management.
Responsibilities
- Establish timely contact with assigned consumers and their authorized representatives.
- Conduct comprehensive assessments of medical, functional, social, and environmental needs.
- Gather and maintain informed consent forms, assessments, supporting records, and other required documentation.
- Identify barriers to community transition and develop strategies to address them.
- Develop individualized, person-centered care plans that support successful community living.
- Coordinate services and supports with healthcare providers, community agencies, family members, and interdisciplinary team members.
- Monitor service delivery and recommend changes to ensure participant needs are met.
- Collaborate with housing coordinators, transition coordinators, facility staff, and state partners throughout transitions.
- Participate in discharge planning and transition meetings.
- Coordinate community-based services, supports, and authorizations needed for discharge.
- Ensure emergency backup plans and required documentation are completed before transition.
- Support participants and families through all phases of the transition process.
- Provide post-transition follow-up and quality management services.
- Maintain regular contact with participants according to program requirements.
- Monitor participant stability, address concerns, and facilitate access to additional resources as needed.
- Complete incident reporting and documentation in accordance with program standards.
- Participate in team meetings, trainings, and statewide initiatives.
- Collaborate with agency staff, state partners, healthcare providers, and community organizations.
- Demonstrate flexibility and support consumers and team objectives.
Benefits
- 15 days of paid time off during the first year.
- 12 paid holidays annually.
- Comprehensive medical, dental, and vision insurance.
- 403(b) retirement plan with a 3.5% employer match after six months of employment.
- Mileage reimbursement for approved business travel.
- Professional development and training opportunities.
- Supportive, collaborative work environment.
- Hybrid work schedule available after successful completion of orientation and training.
- Monday–Friday schedule, 8:30 AM–4:30 PM, with no evening, weekend, or holiday work.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
