AFC Care Manager: On-Site Senior Care & Coordination

LifeStream, Inc.; Michigan; On-site; USD 50,000 - 61,000; Full time

Job summary

LifeStream, Inc. is seeking a social services professional to conduct on-site visits with AFC members and caregivers, coordinate referrals and preadmission assessments, and collaborate with MassHealth for authorization documentation.

The role involves gathering medical and psychosocial information, performing evaluations, and developing person-centered AFC Plans of Care with the multidisciplinary team. Strong communication and organizational skills are essential.

Qualifications

• Bachelor's degree required in Social Work, Human Services, Nursing, or related field.
• Experience working with older adults or individuals with disabilities.
• Knowledge of care coordination and community-based services.
• Strong communication, organizational, and interpersonal skills.

Responsibilities

• Conduct required on-site visits with AFC members and caregivers per service level and MassHealth regulations.
• Coordinate AFC referrals, intake activities, and preadmission assessments with the AFC RN and Director of Community and Family Services.
• Coordinate with MassHealth or PAO to obtain initial clinical assessments and required authorization documentation.
• Obtain and review medical, social, and psychosocial information to support AFC admission and ongoing service delivery.
• Obtain social history and conduct psychosocial evaluations per MassHealth requirements.
• Evaluate member's psychosocial status and placement appropriateness for AFC.
• Develop, implement, and review each member's AFC Plan of Care with the team and responsible parties.
• Ensure the Plan of Care reflects strengths, needs, goals and resources.
• Assist in developing measurable, person-centered goals and interventions addressing medical, social, emotional, and functional needs.
• Monitor Plan of Care implementation and address concerns needing follow-up or review.

Skills

Care coordination knowledge

Communication skills

Organizational skills

Multitasking with multiple cases

Education

Bachelor's degree in Social Work, Human Services, Nursing, or related field

Job description

LifeStream, Inc. is seeking a social services professional to conduct on-site visits with AFC members and caregivers, coordinate referrals and preadmission assessments, and collaborate with MassHealth for authorization documentation.

The role involves gathering medical and psychosocial information, performing evaluations, and developing person-centered AFC Plans of Care with the multidisciplinary team. Strong communication and organizational skills are essential.