Elderly Services Program (ESP) Care Manager and Intake Assessor

Overview

Responsible for fulfilling a dual role as an Intake Assessor and Care Manager. Will fulfill Care Management duties for a partial case load. Provide care management for clients of the Elderly Services Program (ESP), including completing assessments to determine client need, develop service plans, make collateral referrals, coordinate services and ongoing client status, conduct client visits including in home and/or facilities. Will act as a full time Care Manager when directed in order to provide case coverage in the event of a Care Manager vacancy. Will fulfill duties of an Intake Assessor, screening referrals for eligibility to enroll in the Elderly Services Program and providing information and referral to individuals via phone or electronically.

Responsibilities

• Maintain Client Caseload:
• Assess client referrals for program eligibility according to program policy and procedures; enroll eligible individuals
• Develop individualized service plans in collaboration with client and/or caregiver that includes community resources as well as ESP services
• Provide information and referral as needed Provide information, referrals, and/or resources as needed.
• Inform clients of rights and responsibilities
• Monitor service plan costs to ensure we adhere to cost caps, per procedure
• Secure and monitor services to ensure quality of care to support the health and safety of the participants
• Maintain the client contact schedule of required interventions (phone or home visits) to assess and verify the service plan; identify any problems in service delivery and assess for any changes in client status, conditions or needs; provide support and assistance as needed and assure ongoing eligibility
• Complete documentation as required per procedure
• Maintain ongoing contact and open communication with caregivers, family members, friends and other sources of informal support as appropriate
• Work with clients, service providers and others involved in the client’s plan of care in mutual problem solving and coordination of care as needed.
• Complete review of income and medical expenses to determine client co-payment amount if applicable. Monitor client’s co-payment status
• Insurance, Medicare, Medicaid, Advantage plans, referrals to benefit specialist, payor of last resort, pursues other funding sources
• Assist client/caregiver with discharge planning as appropriate upon disenrollment from ESP and/or from hospital/nursing home as appropriate.
• Follow policy and procedure for processing client appeals and participate in appeal proceedings as required; disenroll clients who no longer meet eligibility requirements in accordance with policy and procedures
• Cooperate with care management team to assure adequate and appropriate care management coverage of all agency clients.
• Intake Duties:
• Provide information and referral about aging network and services as well as other community resources to callers.
• Complete telephone assessments for Elderly Services Program and send new enrollments to designee for case assignments
• Enter screening information into the designated software system per procedure.
• Maintain records and complete reports as needed or requested.
• Assist with online referrals and/or questions submitted via website. Maintain open lines of communication with hospitals, community agencies and other referral sources.
• Assist with maintenance of internal resource data base.
• Administrative:
• Maintain accurate and confidential computer record of client activity using care management software
• Adhere to confidentiality policy and HIPAA protocol as related to all client information/interactions
• Follow-up on reported incidents and health and safety issues. Complete incident reports and/or complaint form as necessary
• Participate in the PQI process as directed by supervisor or manager to include peer audits and supervisory chart audits.
• Time keeping
• Promote a positive community image at all times
• Meetings:
• Attend required program and agency trainings and meetings
• Participate in case conferences
• Attend professional meetings, workshops, seminars as appropriate
• All other duties as assigned and/or appropriate to the position.
  

Qualifications

Education and Licenses or other required certifications: Licensed Social Worker OR Registered Nurse OR Bachelor’s prepared degree in social work, gerontology or related field. Must have an acceptable criminal records check as defined in the ODA criminal records check rule 173-14-01. Appropriate experience may suffice; approval required by program Administrator.

Experience: Prefer at least one year experience in geriatrics, case management, intake/interviewing, long-term care, home health or medical social work.

Specialized knowledge, skills, or abilities: Must possess excellent communication and organizational skills. Must be proficient in basic computer applications. Must have valid drivers license, insurance, reliable transportation and ability to complete home visits. Must receive AIRS Certification within the first year of employment.