LTSS Supports Coordinator (Meridian MMP) - Van Buren County, MI at ConcertoHealth
Kalamazoo, MI, US

Job Details


The Long Term Supports and Services Supports Coordinator works within a team environment partnering with the Care Coordinator (RN) to advocate and coordinate the continuum of care for our patients. This role requires a high level of interaction with our patients to:
• Perform effective outreach to complete necessary health and social assessments
• Engage them in the development of an integrated, patient-centered care plan that takes into account needs across the continuum of care (health, social, psycho-social)
• Support the patient in achieving their own goals as stated in the care plan as well as monitor adherence to treatment plans or other disease/chronic condition management programs
• Work with a multi-disciplinary care team to develop interventions and changes to the care plan in response to patient’s needs and promotes positive health outcomes. 

• Perform comprehensive, team-based, and person-centered patient engagement
• Document patient care plan tasks, goals, and interventions using appropriate mediums (e.g. EMR, historical claims data, outreach logs, etc.) in care coordination record system
• Identifies caregiver training needs and tracks impact of needs and or training
• Conduct discharge planning/coordination to ensure all post-discharge LTSS services required are in place Identify the appropriate utilization of resources across the continuum of care
• Maintain patient/caregiver care plan compliance
• Participate in quality improvement and evaluation processes
• Perform and document reassessments, revisions to care plans, and coordinate interdisciplinary care team meetings in accordance with the (health plan) model of care requirements
• Conduct face to face visits in member’s homes at a minimum of every 90 days, or as scheduled per member needs.
• Complete all mandatory regulatory and other trainings required (including but not limited to: compliance training, first tier downstream and related (FWA) entity training, model of care training, etc.
• Completes multiple comprehensive assessments to determine qualification for additional supports and services.
• Collaborates with multiple team members (LTSS Coordinator, Care Coordinator, Patient Care Coordinator, and Management)
• Assists with identification of high risk members that require a high intensity of care coordination and frequent contact
• Coordinates community resources depending upon member needs
• Provides assistance to identify the appropriate LTSS resources across the continuum of care
• Other duties as assigned

• LLMSW, LMSW, LBSW license in the State of Michigan
• Bachelor’s degree or higher from a CSWE-accredited social work program
• Minimum of three (3) years clinical experience, HMO /Managed Care setting preferred
• Care Coordination/ Case Management training Knowledge community resources. Knowledge of clinical standards of care. Knowledge of Medicaid/Medicare contracts and benefit systems is preferred.
• Local travel required for home visits, meetings with families, and other regularly meetings are required.
• Willingness to adhere to spending required time in the office at the discretion of Management
• Professional, flexible, and patient centered “team player” mentality

We are an Equal Opportunity Employer