Transition/Custodial Prevention Specialist
About The Position
As a Transition/Custodial Prevention Specialist, you will work one-on-one with members to create personalized care plans, coordinate services, and empower them to achieve better health outcomes and greater independence. You will meet members in the field at home, Nursing Facility (NF), or location of the member's choice. You will spend quality time assessing their goals, needs, and barriers. Then, you will connect members with quality services to promote their ultimate well-being and drive person-centered health outcomes. Provide specialized support for members receiving Long Term Services and Support (LTSS), with a focus on addressing health-related social needs (HRSNs), providing psychosocial support, and ensuring LTSS meets the member's service needs. Support members residing in NFs by building relationships with facility staff, advocating for member care (including access to needed behavioral health services), and assessing the member's desire and ability to return to the community.
Requirements
- Must reside in the state of Illinois.
- Bachelor's degree in social sciences, social work, human services, or a related field.
- Two (2) years of experience working with Medicare and Medicaid recipients, long-term care services, Home and Community-Based Services (HCBS), or managed care organizations.
- One (1) or more years of professional experience working with members in custodial and transitional care.
- Experience using a variety of electronic information applications/software programs including electronic medical records.
- Ability to travel in the region to meet face-to-face with members and/or their families, community partners and care teams.
Nice To Haves
- An active, unrestricted Licensed Professional Counselor (LPC), Licensed Social Worker (LSW) or Registered Nurse (RN) in Illinois.
- Nursing home diversion or long-term care case management experience.
- Experience working with a Waiver Program.
- Experience with Medicare & Medicaid recipients.
- Experience working with complex health population.
- Experience with health promotion, coaching and wellness.
- Knowledge of community health and social service agencies and additional community resources.
- Bilingual or Multilingual: English/Spanish, Arabic, Vietnamese, Amharic, Urdu or other.
Responsibilities
- Contact members telephonically and face-to-face to establish goals and priorities, evaluate resources, develop plans of care, and identify LTSS providers and community partnerships to provide a combination of services and supports that best address the needs and goals of members and caregivers through person centered thinking approaches.
- Focus on supporting members or caregivers utilizing an interdisciplinary approach in accessing long term services and support, social, housing, educational and other services, regardless of funding sources to meet their needs.
- Develop and modify Individual Service Plans and involve applicable members of the care team in care planning (Informal caregiver coach, PCP, etc.).
- Support members through navigation of their LTSS and related environmental and social needs.
- Utilize available information pertaining to members to prevent the need for administration of duplicative assessments.
- Make recommendations for appropriate Home and Community-Based Services (HCBS) to enable member's independence in the community.
- Facilitate interactions with other payer sources, providers, and interdisciplinary care teams.
- Educate members in maintaining Medicaid eligibility.
- Assist with entry of annual Level of Care assessment into state portal.
Benefits
- medical
- dental
- vision benefits
- 401(k) retirement savings plan
- time off (including paid time off, company and personal holidays, paid parental and caregiver leave)
- short-term and long-term disability
- life insurance
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
