The DSCC Care Coordinator (Medical Social 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 Medical Social Consultant is expected to engage and develop strong partnerships with families through care coordination activities, including: completing comprehensive assessments, person-centered care plans, monthly interactions, engagement with multiple stakeholders, and coordination of resources.

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.

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 compliance case record compliance as established by procedures.

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.

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

Conducts and documents in-person visits at home or other appropriate settings like schools or hospitals every 6 months or as needed according to federal waiver requirements.

Partners with team members (e.g., home care liaisons or nurse consultants) to facilitate seamless transitions of care.

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 the 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).

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.

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

May take the lead on the management of complex behavioral health individuals until the participant is stabilized or moved to a lower level of care coordination management.

May manage clinically and socially complex caseload participants resulting from neglect or abuse allegations, illness progression, or caregivers’ hardship.

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).

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

Active participation in post-records reviews and completion of recommended remediation within 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 support other licensed and unlicensed care coordinators in verifying and interpreting clinicalconditions, treatments, mental or behavioral health diagnoses or concerns,guiding priorities on the person-centered care plan, and recommending resources.