Service Coordinator is responsible for assessing member’s functional and medical needs to collaborate with providers and coordinate and case/care management to STAR+PLUS and/or MMP Members residing in Nursing Facilities. The Service Coordinator has an overarching philosophy of providing quality care in the least restrictive environment promoting independent living, self-determination, and community integration.
Primary Duties and Responsibilities:
- Conducts a comprehensive F2F (Nursing Facility assessments) 4 times per year with Members residing in a Skilled Nursing Facility.
- Attends and actively participates in Nursing Facility care plan meetings for assigned Members to collaborate with nursing facility staff to mitigate barriers to care and prevent hospitalizations.
- Collaborates with transition team to create a viable discharge plan for members expressing desire to return to the community through MFP process.
- Works with member, member’s family, nursing facility and providers to develop a comprehensive
Individualized service plan.
- Uses clinical judgment to identify physical and behavioral health needs and works with the member and caregiver to establish an appropriate plan of care to ensure needs are met.
- Works with member to close functional, clinical, and pharmacy gaps.
- Acts as a liaison and facilitates the coordination of benefits, resources, healthcare providers, and institutions.
Completes and files all assessments within the timelines outlined by the state.
- Maintains a maximum weekly face to face visit schedule of twelve members with average caseload of 120.
- Must be a Registered Nurse with a current, unrestricted Texas License
- Strong organizational and time management skills
- Must have strong computer skills using MS office products including Word, Excel, and Outlook
- Excellent verbal and written communication skills
- Must have reliable transportation, a valid and unrestricted driver’s license and proof of insurance.
- The ability to travel to members’ homes, and other locations within the service delivery area.
- Previous STAR+PLUS experience.
- Home Health Case Management experience with Medicare or Medicaid populations a plus
- Experience managing members with chronic disease processes and
- Experience working with community resource organizations preferred
- Experience with care management software applications preferred.
Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.