Position Responsibilities: The Long Term Supports Coordinator (LTSC) integrates non-medical support services into care plans and assists the members/enrollees of the One Care Plan, their caregivers and the Primary Care Team in navigating the network of support and information services available to disabled adults ages 21 and older.
Essential Functions: (Core duties or tasks that are fundamental and not marginal to the performance of the job)
- Conducts initial and ongoing assessments on new One Care members/enrollees and completes the required assessment tools and appropriate computer data entry.
- Conduct field visits to assess an older adult’s physical, social, emotional and environmental status to determine their eligibility and needs in their homes in accordance with Executive Office of Elder Affairs regulations.
- Work collaboratively within the team when difficult scenarios and issues arise within a teammate’s caseload.
- Collaborates with the One Care Team to develop a Personal Care Plan that best meet member needs.
- Supports and advocates for person centered planning.
- Arranges, coordinates and authorizes the provision of appropriate non-medical services as directed by One Care program and the Care Team.
- Finds resources and services in the community that support members independence, wellness, and goals of recovery.
- Completes key data elements in appropriate computer databases, which includes but is not limited to demographic data, programs/services and documentation.
- Monitors the outcomes of the developed Personal Care Plan.
- Assists members/enrollees with Medicaid redeterminations, securing Social Security and S.S.I., food stamps, housing and other related benefits.
- Participates in the organization and promotion of health related programs and activities.
- Attends Interdisciplinary Care Team meetings as required.
- Participates in Team meetings and activities as a team member.
- Other duties as assigned.
BA/BS in social work, human services or related field strongly preferred. Experience working with adults with physical, intellectual, and behavioural disabilities strongly preferred. Experience with disabled population or elders in a health care setting preferred. Knowledge of home and community based service systems preferred. Cultural competency and the ability to provide informed advocacy preferred. Ability to adapt to a variety of situations, and to respect and accept different values, nationalities, races, religions, sexual orientation, expressions of gender, cultures, and standards of living. Strong written, verbal, computer and skills necessary to work successfully in an interdisciplinary team required. Must have valid Driver’s License and reliable transportation.
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