The Long-Term Support Services Coordinator (LTSSC) is the Care Manager assigned to work with One Care Plan enrollees and is a Primary Care Team (PCT) member. The LTSSC is responsible for coordinating and providing community social services to One Care Plan enrollees in accordance with the plan’s policies, procedures, and practices. The LTSSC assists in promoting the plan enrollee’s independent functioning in the most appropriate, least restrictive setting. 

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES:

• The Long-Term Support Services Coordinator (LTSSC) is a member of the Primary Care Team (PCT) and participates in Initial and Ongoing Assessments of the health and functional status of enrollees, including determining appropriateness for institutional long-term care services and developing community-based care plans and related service packages necessary to improve or maintain an enrollee’s health and functioning.
• The LTSSC arranges, coordinates, and authorizes the provision of appropriate long-term care and social support services for enrollees; with the agreement of the PCT and in accordance with requirements set forth by the plan. It may include but is not limited to ADL and IADL assistance, housing, home-delivered meals, and transportation. 
• The LTSSC monitors the appropriate provision and functional outcomes of community long-term care services, which the PCT has authorized. 
• The LTSSC tracks enrollee transfer from one setting to another (for example, hospital to home or nursing home to adult day health) and adjusts the service plan as deemed appropriate by the PCT and in accordance with requirements set forth by the plan.
• The LTSSC participates in case conferences with the PCP, Nurse Care Managers, and representatives from other disciplines to identify the optimal care plan for plan members.
• The LTSSC responds in a timely manner to enrollee service requests. 
• The LTSSC collaborates with the PCT, the enrollee, the designated representative, and community-based services providers to determine appropriate discharge plans after admission to an institution.
• The LTSSC prepares documentation for enrollee files and ensures appropriate and timely entries and updates of enrollee information available in the Centralized Enrollee Record (CER). 
• The LTSSC has a working knowledge of SAMS and plans CER to enter and retrieve data.
• The LTSSC performs all services in accordance with state and federal law and each written plan’s management protocols. 
• Report suspected Fraud, Waste and Abuse (FW&A) as required by CBES FW&A policy. 
• Protects Consumer’s Personal Health Information (PHI) and reports any suspected security breaches.
• The LTSSC attends and participates in agency and departmental meetings and training as required. 
•  Other duties as assigned. 

QUALIFICATIONS:

• Bachelor’s degree in social work or human services or at least two years working in a human service field with demonstrated experience working with the elderly/disabled population. 
• Previous experience with person-centered planning and per-centered direction training.
• Must have knowledge and experience collaborating with people with disabilities, behavioral health needs, or elders needing LTSS.
• Must have knowledge of the home and community-based service system and how to access and arrange for services. 
• Must have experience conducting LTSS needs assessments and monitoring LTSS delivery.
• Working knowledge of cultural competency and the ability to provide informed advocacy.
• · Must be able to write an ICP and communicate effectively, both verbally and in writing, across complicated service and support systems and meet all the requirements of their CBO employer.

PHYSICAL REQUIREMENTS OF THE JOB:

• Ability to lift and carry objects frequently weighing up to 10 to 15 pounds.
•  Ability to climb stairs.
• Ability to travel to the community to visit consumers’ homes.
• Work requires regular standing, stooping, and bending.