THIS IS A TEMP TO PERM POSITON!!!
100% field work and 100% face-to-face member interaction.
Essential Functions:
- Completes UAS and other relevant screening and assessment tools in the member home.
- Ensures continuity of care for newly enrolled members. Identifies and prioritizes the members needs and preferences. Develops quantifiable goals and desired outcomes, and promotes the members ability to self-manage to the greatest extent possible.
- Develops, implements and monitors the Person Centered Service Plan, assisting members in obtaining reasonable accommodations when appropriate.
- Manages case load, including risk stratification of members, monitoring reassessment needs and facilitating transitions of care settings. - Serves as the primary point of member contact. Assesses member needs, manages care and services, and ensures effective communication among members, caregivers, providers and community supports.
- As the lead of the interdisciplinary team, facilitates the activities and communication within an interdisciplinary team of providers, vendors, facilities, discharge planners, field nurses, social workers, care coordinators, and member/caregivers to effectively manage care plans and transitions of care settings.
- Maintains timely, complete and accurate documentation using both hard copy and technology based solutions in compliance with regulatory policies and procedures.
- Gathers and summarizes data for reports.
- Supports initiatives of the Quality Assessment and Performance Improvement Committee.