Care Coordinator

Education:

Specific Responsibilities:

• Reviews financial, medical, and social information of applicant as presented by referral source.
• Verifies Medicaid eligibility and/or screens for MAO/PMAO eligibility, using standardized guidelines.
• Explains thoroughly the scope and purpose of the CCSP.
• Identifies client’s needs and desired services as stated by the referral source or applicant.
• Researches and maintains up-to date knowledge of community resources.
• Collaborates with the RN care coordinator and client’s physician to discuss the plan of care needed and define appropriate services and service setting necessary to maintain or improve the health/functional status of the client. Provides information on the availability of services, delivery options, and on the feasibility of implementing the service needs identified by the RN. In cooperation with the RN, determines the cost for implementing the plan of care for the client.
• Develops the comprehensive care plan and initial service order in coordination with the RN care coordinator and consultation with the client, client’s family, and service providers.
• Serves as the liaison between the assessment process and the effective delivery of direct services.
• Brokers the CCSP services and implements the care plan.
• Arranges for non-CCSP community-based services needed by the client.
• Notifies RN care coordinator of any change in client status.
• Monitors service delivery to individual clients to assure services are being provided as appropriate and effectively meets the client’s needs.
• Continuously reviews, monitors, and updates the comprehensive care plan.
• Documents case activity and service information in a timely manner.
• Communicates and coordinates with all agencies providing direct services to the client.
• Approves/denies providers’ requests for increased services based on the care plan and needs of the individual. Limits amount and frequency of service in order to assure that costs do not exceed the limitations established by the Division of Aging Services and the Department of Medical Assistance.
• Conducts face-to-face contacts with each client as needed/or at a minimum of 90 days in order to provide effective care coordination. Completes the CCP Review.
• For dual CCSP/HCBS clients, performs HCBS assessments, nutritional screening, and reassessment for the Nutrition Program for the Elderly and sends the appropriate forms to data entry.
• Completes a full reassessment on those clients where there is no significant change in functional status. Requests RN to perform the reassessment if there is a significant change in functional status, post nursing home stay or post hospital stay, if justified.
• Reports suspected abuse, neglect, or exploitation of any client to APS if client does not live in a PCH or to LTCO and ORS if client lives in a PCH. Reports information to the ALS family model provider, if appropriate. Reports suspected abuse, neglect, or exploitation of any client to law enforcement.
• Arranges emergency services when applicable.
• Advises supervisor of the need for any case conference to resolve client conflicts or service issues. Notifies all parties concerned and attends case conference as client’s advocate.
• Completes the Service Authorization Form (SAF). De-authorizes unused services timely. Continuously reviews, monitors, and updates the Service Order form.
• Sends necessary information to DFCS office when LOC is returned and services begin.
• Communicates with DFCS regarding MAO/PMAO eligibility.
• Maintains confidential case records on all CCSP and dual CCSP/HCBS clients.
• Requests redetermination of the client’s level of care prior to its expiration or if there is a change of status or new services required.
• Advocates for the special needs of the functionally impaired population requiring community based services.
• Maintains knowledge of the provider service standards for each CCSP service.
• Assists clients with appeals and attends hearings. Provides data and client records required by hearing officer as required.
• Attends CCSP Network meetings and other meetings coordinated by AAA.
• Provides support to the Agency and to the Area Agency on Aging to educate the general public, health and social service agencies, physicians and other health professionals, nursing homes, hospitals, health providers, church and civic groups, etc., regarding the services available.
• Compiles and submits to supervisor statistical data on a regular basis.
• Attends organizational meetings and training as required.
• Keeps supervisor informed of progress and problems associated with duties.
• Maintains knowledge of Care Coordination Manual and Provider Services Manual and revisions.
• Must have and maintain a private automobile with proper liability insurance and a valid Georgia Driver’s License.
• Ensures compliance with all State and Federal laws.
• Conforms to Agency Administrative procedures, including Personnel and Fiscal Policies, as well as Administrative directives.
• Responsible for own professional development.
• These duties are not all-inclusive and the employee will also perform other related duties as assigned by the Department Director, Supervisor, or other member of management.