Position Summary:

Assists with planning and implementation of VNH Long Term Care Service programs under the direction of the Long Term Care Service Director. The LTC Case Manager works with a caseload of Medicaid clients ensuring that they have access to resources that enable them to live successfully at home for as long as possible. The LTC Case Manager will work with community partners, OneCare Vermont or any other state or local programs/agencies, as determined by LTC Director.

LTC Case Managers, working as medical social worker assistants (assistant), will provide social services to VNH home health care patients as needed. Depending on the Case Manager’s qualifications, they may be required to provide skilled nursing or medical social worker assistant visits to clients in our Longitudinal Care Program or other Medicaid programs. These programs include (but are not limited to):

Choices for Care: This is a Medicaid program designed to support nursing home level of care clients in their homes for as long as possible.

Moderate Needs Care: This is a Medicaid program designed to support clients who are mostly independent but still need assistance with Instrumental Activities of Daily Living.

OneCare: OneCare Vermont is a provider-led Accountable Care Organization working to improve the health of Vermonters and lower health care costs. OneCare partners with health insurance companies, hospitals, independent medical practices, and community collaborators to offer interventions that lead to positive healthcare outcomes. OneCare gives doctors and other provider’s access to data, resources, and tools to improve patient health. Interventions focus on improving access to primary care and preventive medicine, thereby reducing ER visits and hospitalizations and leading to more effective management of chronic illness, mental illness and addiction.

Longitudinal Care Program: The Longitudinal Care Program (LCP) offers support and care management for High Risk patients who are no longer eligible for traditional home health care. Enrollment in the LCP allows for continued tele monitoring and RN case management with monthly home visits between skilled care episodes, and additional support from assistant and Community Health Workers as needed.

Principal Duties and Responsibilities:

Provide case management to clients and families receiving long term care services (Medicaid).

Assist with timely resolution of patient and family problems by completing assessments including establishing goals and following through with referrals to community services as needed.

Case management may include issues related to paraprofessional services, legal, financial, spiritual, emotional and/or interpersonal concerns.

Supervise and evaluate care provided by VNH PCAs.

Attend Community meetings as indicated-represent VNH in the community, establish collegial working relationship with community partners.

Monitor and access Care Navigator, Workbench One, and Portal databases for OneCare program.

Educate, assist and track staff to use the Care Navigator database, Develop Person Centered plans, Conduct Care Conferences, and Coordinate Care.

Coordinate/provide services to the Longitudinal Care Pilot Program with VNA’s of Vermont.

Knowledge of and access to Community Resources.

Work collaboratively with VNH liaisons and staff across VNH programs.

Data Entry for Care Navigator.

Competencies:

Stewardship – support practices and communicates the VNH Mission and Statement of Values

Problem Solving – interact with clients, resource agencies and co-workers in a positive and collaborative manner to achieve positive outcomes

Planning and Organizing – collaborate with team members and community resources to achieve effective and achievable goals

Quality – advocate for best outcomes

Safety – promote and support self-management of healthy behaviors

Minimum Qualifications:

Bachelor’s degree in social work or related field or LPN/RN

Two years of experience in health care or related field