Statewide in Illinois - Care Coordinator (Nursing Consultant)

The DSCC Core/Connect Care Nursing Consultant provides care coordination services to families eligible for DSCC programs. Under the direction of the regional manager and assistant directors, the position is responsible for knowing and abiding by specific program contractual requirements. The Nursing Consultant is expected to engage and develop strong partnerships with families through completing comprehensive assessments and person-centered care plans, monthly interactions, and coordination of resources. It also offers consultation to other members of the multi-disciplinary team utilizing skills and knowledge acquired from academic training and professional experience as a Registered Nurse.

Duties & Responsibilities:

Under the direction of the regional manager, performs active care coordination services by completing comprehensive health assessments, identifying families' strengths, and developing a person-centered service and care plan.

Facilitates 30-day ( or as needed) monitoring of the person-centered care plan, assesses/determines status change, prioritizing unmet needs and location of resources.

Utilize a culturally – competent approach as guided by the university to support families’ cultural values and traditions.

Utilize as necessary interpreter language line and accommodation resources based on the university’s Americans with Disability Act (ADA) guidelines, such as American Sign Language (ASL).

Join and participate in Medicaid managed care clinical rounds occasionally.

Join and participate in DSCC multidisciplinary meetings as needed.

Engage as necessary with the transition of care team to promote effective discharge planning.

Educate, support, and connect families with resources for a seamless age transition.

Provide close collaboration with MCO teams for those participants that are co-managed (e.g., waiver recipients).

Conduct and document in-person visits at home (every 6 months or as needed) or in other appropriate settings like schools or hospitals.

Completes consistent and timely documentation (within 48 hours) to ensure case record compliance as established by procedures.

HC nurses will educate, support, and connect non-waiver families with resources for a seamless age transition. Similarly, provide age-transition support to waiver families exiting the program due to health improvement.

HC nurses will complete consistent and timely documentation (within 48 hours) to ensure compliance with waiver and non-waiver renewal requirements and timelines without direct manager support.

HC nurses will conduct and document in-person visits at home or other appropriate settings like schools or hospitals every 6 months or as needed according to federal waiver requirements.

Identifies critical incidents and collaborates with all involved providers for resolution.

Manages clinically complex caseload participants resulting from neglect or abuse allegations, illness progression, or caregivers’ hardship.

Apply effective communication skills to improve families’ health literacy.

Arrange, lead, and contribute with areas of expertise to multi or interdisciplinary care team meetings with participants’ providers, family members, nursing agencies, or school teams.

Identify/escalate and facilitate internal team meetings on participants with complex behavioral/social determinants or clinical factors impacting their well-being.

Active participation in post-records reviews and completion of recommended remediation within the expected timeline.

Contribute to quality improvement initiatives, including but not limited to attendance at quality huddles and provision of recommendations as needed.

Assist families and caregivers with the coordination of medical services, required treatments, supplies/equipment, and environmental modifications.

May mentor/coach care coordination team members and participants/caregivers on self-management of chronic diseases, medication adherence, and prevention.

May contribute as a subject matter expert on health education initiatives such as immunizations, weight management, the importance of physical activities, etc.

May support other licensed and unlicensed care coordinators in verifying and interpreting clinical conditions, treatments, mental/behavioral health diagnoses or concerns, guiding priorities on the person-centered care plan, and recommending resources. 

Assists families with private/public health insurance through effective benefits management practices for recipients.
Identify financial needs and assist with the completion of DSCC financial application, and annual redetermination.

Competent collection of documentation to support administrative/prior approvals for Core eligible services, and utilization of other resources like gift funds.

Complies with the University, Division, and Regional Office policies, and procedures.

Performs other duties and special projects as assigned.