Conducts face-face assessments/reassessments from a clinical perspective on designated assigned cases.

· Obtain medical history and document pertinent clinical information from participants related to their medical diagnoses and assessment findings

· Utilizing assessment, develops a plan of care directed by the client (Person Centered Care Planning)

· Monitor participants for conditional changes associated with their physical and mental health well-being

· Preforms monthly medication reconciliations

· Develops and completes care plans and other required documents. Reviews and modifies care plans as directed by the client / caregiver during the reassessment and obtains the clients signature of approval.

· Maintains regular, ongoing contact with clients, caregivers, physicians and service providers listed on service plan through home visits and phone calls.

· Educates clients, caregiver and service providers regarding the roles and responsibilities of each party, assuring that services are provided as documented in the care plan.

· Conducts Nursing Facility Level of Care assessment as required.

· Continues to evaluate the appropriateness of the service plan, adjusting it as needed.

· Monitors client progress in relation to goals and objectives listed in the care plan.

· Interfaces with community resources as needed to support client.

· Collaborates with peers (RN or SW) in coordinating services.

· Produces timely and accurate commuter entry reports.

· Maintains client confidentiality

· Participates in training, supervisory meetings, in-services and continuing education opportunities.

· Abides by DAAA’s and Waiver Codes of Ethics.

· Participates in other duties as assigned.

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