Home & Community Based Services RN-PHN-SW

The Home and Community Based Services (HCBS) Lead position is responsible to determine level of care for individuals needing an institutional level of care and assisting persons with long term or chronic care needs in making care decisions and selecting support and service options that meet their needs and reflect their preferences. This position will be the first point of contact for HCBS service options and planning. Collaborates to promote service accessibility and provide comprehensive coordination of services to meet the needs of clients across the continuum of social services, public health, medical and other community services. This position is responsible for implementing the required Local Public Health Activities that are organized according to the following areas: assuring adequate local public health infrastructure; promoting healthy communities and healthy behavior; preventing the spread of infectious disease; protecting against environmental health hazards; preparing for and responding to disasters and assisting communities in recovery; and assuring the quality and accessibility of health services.

Duties and Responsibilities
• Manages intakes for service requests. Discusses and determines needs, service options, eligibility and program procedures with families and guardians of clients.
• Processes intakes for and completes MnCHOICES assessments and reassessments for Freeborn County consumers and County of Location consumers.
• Completes Community Support Plans that result from an assessment.
• Maintains a reduced caseload and provides ongoing case management including crisis management. Develops case plans and assesses client progress.
• Interprets policies and regulations to clients and their families.
• Collaborates with other community agencies and resources and refers clients to various service providers such as foster homes, nursing homes, mental health and treatment centers, etc. Identifies available and develops new resources, coordinates services for clients and their families, maintains contact to monitor client progress and ensure needs are met.
• Provide care coordination/case management services for enrollees of managed care programs. Performs long term care assessments or other health and wellness assessments and assists individuals with developing plans for (HCBS) and supports.
• Provides consultation for services involving difficult social and financial problems; interprets programs to clients and families; refers clients and families to appropriate services.
• Facilitates family and client meetings to provide on-going support, counseling and assessment. Interviews and assesses the social service needs of a variety of clients as drug dependents, crime victims, families and mentally and physically disabled adults.
• Screens clients for program eligibility.
• Refers clients to a variety of support services such as drug treatment, family counseling, nursing home care, medical treatment, and mental/emotional counseling.
• Develops case plans with obtainable goals and assesses client progress. Monitors and evaluates the quality and appropriateness of client treatment.
• Documents client performance by maintaining up to date and accurate case notes and functional assessment.

Additional Duties and Responsibilities
• Prepares budgets for waivered services.
• Prepares and maintains a variety of records and paperwork related to case management in accordance with county, state and federal rules and requirements.
• Participate in Vulnerable Adult investigations when assigned.
• Attends regional and state meetings and trainings applicable to the position.
• Maintains MnCHOICES Mentor role and trouble shoots and problem solves.
• Participate in and promotes the culture of Quality Improvement within the Public Health Department.
• Maintains current knowledge with rules, statues and regulations.
• Attends required trainings and meetings, including training in a wide variety of computer programs.
• Prepares for and responds to emergencies, events, and incidents, and assists communities in recovery. Responds 24/7, as needed, during a public health emergency.

While these are the primary focus of the position, we believe strongly in teamwork and employees will be called upon to perform a variety of duties as part of their role with the County.

Position Requirements

Knowledge, Skills and Abilities
• Considerable knowledge of medical terminology, nursing practices in general and public health.
• Knowledge of HIPAA, Data Privacy laws and the Nurse Practice Act.
• Knowledge of local, state and federal laws, rules and regulations for nursing and public health.
• Knowledge and understanding of laws governing social services.
• Knowledge of current principles and practices of case management.
• Knowledge of available public and private community health and social service resources and their functions, including funding sources.
• Ability to prioritize and manage time productively.
• Skill in providing technical guidance, mentoring and suggestions on case direction to other case workers.
• Provide work direction to others.
• Skill in applying principles of quality assurance, quality improvement and evaluating program effectiveness.
• Skill in performing and analyzing health assessments.
• Skill in educating about health issues.
• Skill operating computers and relevant software
• Excellent communication skills, both oral and written, and interpersonal skills as applied to interactions with clients, other staff, officials, and the general public.
• Ability to administer rules and procedures under management guidance.
• Ability to use analytical ability to select, evaluate and interpret data and interpret guidelines, policies and procedure.
• Ability to maintain effective working relationships with a wide variety of internal and external contacts to achieve organizational objectives.
• Skills in administering preventative healthcare, such as immunizations.

Education and Experience

Public Health Nurse:
• Bachelor’s degree in nursing with current Registered Nurse License and Public Health Certification from State of Minnesota
• Plus at least 3 years of HCBS experience

Social Worker:
• Bachelor’s Degree in Social Work, preferable with a Minnesota State Social Work License
• Plus at least 3 years of HCBS experience

Other Job Requirements
• Valid Driver’s License or evidence of equivalent mobility
• Maintains AED and CPR Certification
• Must participate in annual training on bloodborne pathogens compliance standards
• MnCHOICES Assessor and Mentor Certification

Equipment and Tools Responsibilities
• Frequently operates office equipment, technology, and medical equipment.
• Intermittently must operate personal vehicles.

Physical and Mental Requirements
This job typically requires: sitting, standing, walking, driving, feeling, manual dexterity, grasping, talking, hearing, typing, and seeing. There is exposure to computer keyboards and video screens. This position is generally light-duty and may require the exertion up to 20 pounds of force, and the ability to push, pull, lift, carry and move objects.

The physical demands described here are representative to those that must be met by an employee to successfully perform the essential functions of the job. Reasonable accommodations can be made to enable individuals with disabilities to perform the essential functions.

Working Conditions
Work is performed in an office, client homes or other indoor or outdoor settings. Worker is subject to variable outside weather conditions. Motor vehicle travel is required.

There is potential exposure to infectious diseases and bloodborne pathogens. Worker may be subject to odors, wetness, poor illumination, and sudden temperature change. Worker may be exposed to dangerous physical and/or environmental conditions (animals, insects, rodents, house in need of repair, drugs, weapons etc.) Worker is exposed to noise, distractions, and interruptions. Worker may be exposed to hostile, verbally abusive, and emotional clients and family members.

Competencies Common to All County Positions
• Develop, maintain a thorough working knowledge of, and comply with all departmental and applicable County policies and procedures.
• Demonstration by personal example the spirit of service, excellence, and integrity expected from all staff.
• Develop respectful and cooperative working relationships with co-workers, including willing assistance to newer staff so job responsibilities can be performed with confidence as quickly as possible.
• Confer regularly with and keep immediate supervisor informed of all-important matters which pertain to the applicable job functions and responsibilities.
• Represent Freeborn County in a professional manner to the public, outside contacts and constituencies.

*****Completed applications along with cover letter and resume are due by 12:00 PM Friday, March 28, 2025. Starting salary $34.07 - $47.70 per hour.

Salary : $34 - $48