LTSS Care Coordinator

POSITION SUMMARY:

The role of the Long Term Supports and Services (LTSS) Care Coordinator is to provide outreach, LTSS care planning, care team participation, LTSS coordination, support transitions of care, provide health and wellness coaching and connect pediatric MassHealth members participating in the LTSS Community Partner program with social services and community resources. The LTSS Care Coordinator will follow defined timelines in order to meet the EOHHS requirements of billable activities. The Coordinator is responsible for documentation in the electronic medical record platform and complying with all data entry, data integrity, and data tracking requirements.

Position: LTSS Care Coordinator

Department: BAP Program

Schedule: Full Time

ESSENTIAL RESPONSIBILITIES / DUTIES:

• Contact and inform Assigned Enrollees of the option to receive LTSS CP supports. The majority of Assigned Enrollees will be ages 3-21.

• Under the direction of the Assigned Enrollee (and/or Assigned Enrollee’s authorized representative, if any), develop a LTSS Care Plan for Assigned Enrollees that agree to participate in the LTSS CP program.

• Ensure that the Assigned or Engaged Enrollee receives necessary assistance and accommodations to prepare for, fully participate in, and to the extent preferred, direct the care planning process and that the Assigned or Engaged Enrollee receives assistance in understanding LTSS terms and LTSS concepts.

• Share with parties who need the LTSS Care Plan in connection with their supports of the Engaged Enrollee related operational activities involving the Engaged Enrollee, including members of the Engaged Enrollee’s care team, and other providers who serve the Engaged Enrollee, including state agency or other case managers.

• Develop a person-centered care plan that encompasses numerous items such as MassHealth State Plan LTSS service(s) or program(s) recommended by the CP Care Coordinator and desired by the Assigned or Engaged Enrollee, other  recommended LTSS desired by the Assigned or Engaged Enrollee. A list of specific social services supports to meet social determinants of health needs.

• Assist Enrollee in navigating and accessing LTSS services or programs and work with Enrollee to eliminate duplication of services.

• Connect Engaged Enrollee to social services and community resources, identify and recommend Flexible services for Engaged Enrollee to develop health and wellness goals.

• Coordinate and collaborate with other case management entities and community resources.

• Participate in case conferences with the PCP, Nurse Care Managers, and representatives from other disciplines to identify the optimal plan of care for plan’s members.

• Complete telephone calls to engaged Enrollees, annual, onsite reassessments, and transition planning and transition coordination within the expected LTSS CP timeframes.

• Provide health and wellness coaching; work with Engaged Enrollee to develop health and wellness goals.

• Attend and participate in agency and departmental meetings and trainings as required.

• Perform other duties as assigned.

Other Duties

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Must adhere to all of BMC’s RESPECT behavioral standards.

(The above statements in this job description are intended to depict the general nature and level of work assigned to the employee(s) in this job.  The above is not intended to represent an exhaustive list of accountable duties and responsibilities required).

JOB REQUIREMENTS

EDUCATION:

• (A.) LICSW or LCSW; or (B.) Bachelor’s degree in social work, human services, nursing, psychology, sociology, or related field; or (C.) Associate’s degree and at least one year professional experience in the field; or (D.) at least three years of relevant professional experience.

CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED:

• Must clear CORI background check.

EXPERIENCE:

• Prior pediatrics experience is preferred.

KNOWLEDGE AND SKILLS:

• Ability to visit consumers in the environment in which they reside such as the individual’s home, apartment, shelter, group home, etc.

• Must possess advanced skills in consumer assessment and be able to assess the physical conditions of the consumer's home as well as the consumer.

• Exhibit interpersonal flexibility, initiative, and teamwork.

• Solid organizational skills

• Second language is preferred

• Ability to use computer systems in various environments (mobile phone, desk-top, tablet).

• Ability to learn and utilize various software programs.

• Acceptance of the right to self-determination.

• Maintains consumers’ rights, privacy and confidentiality in all aspects of the job, including those relating to diagnosis and consumer records.

• Promotes and employs ethical actions at all times with consumer’s families and others.

• Participates in performance improvement activities as requested to do so.

• Identifies and communicates opportunities for improvement.

• Demonstrates excellent customer service by conducting daily activities, communications and interactions in a cooperative, positive and professional manner.

• Proficiently and effectively read, write and communicate in English.

• Communicate in a manner appropriate and respectful to the comprehension level of the consumer and/or family.

• Maintains the responsibility for punctuality and attendance as defined in the agency policy to ensure optimal operation of the program.

• Submits requests for vacation, days off, etc. in accordance with department policy

Equal Opportunity Employer/Disabled/Veterans