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JOB DESCRIPTION 

Role Summary: Under the supervision of the CMD Manager, use person centered principles to assess the medical, functional, psychological, financial, and environmental needs of MI Choice Medicaid Waiver participants. Works with the participant, family members and caregivers to develop a person centered plan, to assist and support the participant to manage their care needs and to provide ongoing monitoring and reassessment of participants. 

Responsibilities and Duties 

• Complete in-home assessments to identify areas of need and service preferences, including determination of frequency and duration of social services required under the care plan. 

• Gather and integrate information from all available sources, including consumer self-reports, reports from family members, guardians and Adult Foster Care providers, documented medical and treatment history, needs surveys, assessments from other disciplines, etc. 

• Utilize motivational interviewing techniques to assess and articulate the motivation of program participants to address specific needs identified during the assessment process. 

• Understand disease progressions in order to collaborate with outside entities (e.g. hospice, skilled care, community mental health services).  

• Understand and identify potential participant issues in health care including nutrition/hydration, continence, physical conditions, etc.  

• Collaborate with physicians, LPN’s and other outside medical staff to determine effective treatment for the participant.  

• Maintain a caseload to complete assessments, documentation and reporting by due dates. 

• Work with Community Resources Department to provide participants, family members, and guardians with complete and accurate information regarding services, supports and other community resources available to meet needs identified during the assessment process. 

• Assist with the development of comprehensive and integrated Individualized Plans of Service with participants and other supports (consistent with principles of Person-Centered Planning, Self-Determination and current Medicaid Guidelines). 

• Conducts in-home reassessment visits collaboratively as an RN/SW Team, completing the SW portions of the reassessment in consultation with RN team member accordingly; Reassess the service needs and preferences of participants as needed, at a minimum every three months. 

• Document all service activities and contacts pertaining to program participants, per contract requirements. 

• Link consumers to community services and supports based on the needs and preferences identified in their Individualized Plans of Service; Work with family members and other volunteer caregivers to maximize available informal support systems.  

• Participate in regularly scheduled clinical supervision, case consultations, department meetings, and staff development sessions to make optimal use of resources for professional growth. 

• Perform within acceptable standards of productivity ensuring compliance with all program standards and guidelines. Complete all documentation with expected timeframes. 

• Participate in Waiver outreach and enrollment activities. 

• Maintain appropriate state licensure or certification and complete all requirements for licensure; 

• Maintain appropriate professional ethics and boundaries. 

• Follow agency and department policies and procedures. 

• Other duties as assigned.