Job Overview
The role serves as the single point of contact for members to coordinate all of the member's care needs across the various service delivery systems and community supports. This full‑time community‑based position requires frequent travel within the assigned territory in DE to members' homes, nursing facilities, and other community‑based settings for individuals enrolled in DSHP Plus LTSS.
Base Pay Range
$40.00/hr - $45.00/hr
Essential Responsibilities
Travel to members' homes, nursing facilities, and community settings to complete face‑to‑face needs assessments and follow‑up by phone, following state and national guidelines.
Assess, plan, coordinate, implement, and evaluate care for eligible members with chronic and complex health, social service, and custodial needs in nursing or home/community‑based settings.
Coordinate care across the continuum of services, ensuring safe, least restrictive, and cost‑effective care.
Facilitate authorization, continuity, and appropriateness of care and services in community or HCBS.
Assist transitions to alternate care settings (hospital to home, nursing facility to community) through an integrated care team.
Educate members or caregivers about health‑care needs, benefits, resources, and long‑term‑care options.
Provide education, resources, and assistance to help members achieve goals outlined in their plan of care, overcoming obstacles to optimal care in the least restrictive environment.
Develop care plans with members or caregivers to identify services and goals.
Identify resources and facilitate referrals to special programs such as disease/chronic condition management, behavioral health, and complex case management.
Collaborate with the member's health‑care and service delivery team (DSHP Plus LTSS Member Advocate, ICT, discharge planners) to coordinate care and community resources.
Assist members in developing backup plans for gaps in provider coverage and ensure approved support services are provided per plan of care.
Evaluate the effectiveness of service plans and make appropriate revisions per policy, procedures, and state contractual requirements.
Document all case‑management services and interventions in the electronic health record.
Adhere to all company, state, and federal privacy and HIPAA and quality performance standards.
Perform other duties as assigned or requested.
Qualifications
Bachelor's degree in Social Work or health, human, or education services and 3 years of experience in long‑term care, home health, hospice, public health, or assisted living; OR
Master's degree in Social Work or health, human, or education services and 1 year of experience in long‑term care, home health, hospice, public health, or assisted living; OR
Registered Nurse or Licensed Practical Nurse and 2 years of experience in long‑term care, home health, hospice, public health, or assisted living; OR
High school diploma or equivalent and three years of qualifying case‑management experience with the aged, including management of behavioral health conditions or persons with physical or developmental disabilities or HIV/AIDS population.
Preferred
One year of home clinical or case management experience
Certified Case Manager (CCM)
Licensed Bachelors Social Worker (LBSW)
Licensed Masters Social Worker (LMSW)
Licensed Clinical Social Worker (LCSW)
Experience with HIV/AIDS, behavioral health, or developmental disabilities populations
Medicare and Medicaid experience
Managed care experience
Skills
Working flexible hours to meet member needs
Proficiency in PC‑based word processing and database documentation (Word, Excel, Outlook)
Reliable daily transportation within assigned territory
Ability to meet regulatory deadlines
Dedicated home workspace for business use and compliance with telecommuter policies
Experience in geriatric, behavioral health, or home health settings
Understanding of cultural competency for target populations
Experience with electronic documentation systems
Cost neutrality budgeting skills
Employment Details
Seniority level: Mid‑Senior level
Employment type: Full‑time
Job function: Other
Industries: IT Services and IT Consulting
Additional Information
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