Medical Social Consultant (Care Coordinator)

Position Summary The DSCC Home Care Coordinator (Consultant) provides care coordination services to families eligible for DSCC's Home Care program. This position is responsible for engaging and building strong partnerships with the families enrolled in the program through monthly interactions, completion of comprehensive assessments, person-centered care plans, and engagement with multiple stakeholders. The Home Care program serves Medicaid non-waiver participants under 21 years and those eligible for the Persons who are Medically Fragile, Technology Dependent (MFTD) waiver program. 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.  Ensure that the participant and/or legally responsible adult understand the waiver services furnished to the participant, estimated frequency, and provider type.  Facilitates 30-day ( or as needed) monitoring of the person-centered care plan, assesses/determines status change, prioritizing unmet needs and location of resources.  Promotes interagency collaboration such as HFS, DCFS, and other community or state agencies committed to the participant's care.  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.  Conduct and document in-person visits at home or other appropriate settings like schools or hospitals every 6 months or as needed according to federal waiver requirements.  May manage clinically and socially complex caseload participants resulting from neglect or abuse allegations, illness progression, or caregivers’ hardship.  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  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  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.  Partners with team members (e.g., home care liaisons or nurse consultants) to facilitate seamless transitions of care.  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 parts for resolution.  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.  May support other licensed and unlicensed care coordinators in verifying and interpreting clinical conditions, treatments, mental or behavioral health diagnoses or concerns, guiding priorities on the person-centered care plan, and recommending resources.  Assists families with private/public health insurance through effective benefits management practices for recipients.  Complies with the University, Division, and Regional Office policies, and procedures. The list of responsibilities is not all-inclusive and could be extended to include other obligations, special projects, or tasks