Essential Functions:

• Facilitates 2 provider Team Meetings per year.
• Is knowledgeable about all waiver services, Medicaid State Plan Services and available non-Medicaid services. 
• Conducts regular monthly home visits either virtually or face-to-face with the participant as required by NYSDOH regulation. 
• Completes the Initial Service Plan and annual Revised Service Plan including sources of support such informal caregivers, non-Medicaid federal and state funded services, Medicaid services and waiver services.
• For full-time Service Coordinator’s, maintains up to a maximum of 25 cases or pro-rated proportionally at 12-13 for part-time.
• Works with the participant on a safe Nursing Home or Hospital stay discharge/discontinuation plan if s/he is leaving the waiver.
• Organizes and maintains individual Service Coordination records and documents as per prescribed policies and procedures and in accordance with NYSDOH NHTD/TBI Programs and agency regulations and guidelines.
• After being selected by applicant, the Service Coordinator develops the individual’s Application Packet by gaining a full understanding of who the person is, his/her life experiences and goals for the future, by interviewing other persons who are of primary importance to the applicant and by reviewing information from current service providers including where applicable, a discharging facility.
• Ensures that the participant understands his/her Waiver Rights and Responsibilities.
•  Ensures that the service plan (SP) is implemented in a timely fashion by facilitating coordination, communication, and cooperation between all sources of support and services for the participant.
• · Complies with all applicable federal and state regulations and guidelines as well as agency and division policies and procedures.
• · Maintains records for at least 6 years after termination of waiver services.
• · Ensures that the participant is provided information regarding abuse/neglect prevention and how to report any incident of abuse/neglect. Completes and follows up upon Serious Reportable Incidents according to state regulations.
• · Assures that Team Meetings are held at least 60 days prior to end of the most recently approved SP and/or on an as needed basis.
• · Assists the participant in locating a place to live in the community, when necessary, by developing relationships with real estate brokers, and viewing apartments.
• Assists the applicant in applying for Public Assistance, the NHTD Housing Subsidy, HEAP and other entitlements and benefits. Coordinates with other NHTD providers to ensure that Community Transition Services, Assistive Technology, Environmental Modification, Moving Assistance and Home and Community Support Services are in place prior to the move.
• · Establishes and maintains a tracking system for all required documentation including but not limited to level of care evaluations, service plan updates, PRI/SCREEN and UAS.
• · Documents all contacts, visits and meetings involving the participant and records them in a timely manner.
• · Provides on-call coverage as assigned on a rotational basis.