Care Coordinator

Kandiyohi County; Willmar (MN); On-site; USD 78,000 - 109,000; Full time

Job summary

Kandiyohi County in Minnesota seeks a Care Coordinator to support older adults and individuals with long-term care needs by coordinating services, completing MnCHOICES assessments, and helping access programs that promote independence.

You will partner with families, providers, and community partners to assess needs, develop person-centered service plans, monitor eligibility, and adjust plans as needs change. A bachelor's in social work or related field and valid driver’s license are required.

Qualifications

• Bachelor’s degree in Social Work or a closely related human services field required.
• Registered Nurse or Public Health Nurse.
• Two (2) years of related experience preferred, or an equivalent combination of education and experience.
• Valid driver’s license and reliable transportation required.
• Must pass a criminal background check and meet DHS requirements for working with vulnerable populations.

Responsibilities

• Provide care coordination for MSC+ and MSHO, and SNBC products.
• Provide case management for Alternative Care and Elderly Waiver.
• Conduct MnCHOICES assessments to identify needs and eligibility.
• Develop, implement, monitor, and update person-centered service plans.
• Complete eligibility documentation, authorizations, assessments, and care plans.
• Coordinate services with providers, facilities, and community partners.
• Maintain confidentiality and comply with data privacy requirements.

Skills

Person-centered care

Assessment

Care coordination

Interdisciplinary teamwork

Documentation

Education

Bachelor’s degree in Social Work or related field

Registered Nurse or Public Health Nurse

2 years of related experience preferred

Tools

MnCHOICES

Case management systems

Job description

The hiring range for this position is $78,001 - $87,236. The full range for this position is $78,001 - $109,112. The Care Coordinator plays an important role in supporting older adults and individuals with long-term care needs in Kandiyohi County by coordinating services, conducting MnCHOICES assessments, and helping individuals access programs and supports that promote independence, safety, and quality of life. Primary responsibilities include care coordination for Prime West Health Minnesota Senior Care Plus (MSC+) and Minnesota Senior Health Options (MSHO) products, Special Needs Basic Care (SNBC), Alternative Care and Elderly Waiver case management, and Relocation Service Coordination for nursing facility residents. This position works closely with individuals, families, healthcare providers, health plans, nursing facilities, service providers, and community partners to assess needs, develop person-centered service plans, coordinate services, and monitor ongoing eligibility and service effectiveness.

• Provide care coordination for individuals enrolled in Prime West Health Minnesota Senior Care Plus (MSC+) and Minnesota Senior Health Options (MSHO), and Special Needs Basic Care (SNBC) products
• Provide case management services for individuals receiving services through the Alternative Care and Elderly Waiver programs.
• Conduct ongoing assessments of client needs, strengths, preferences, goals, health and safety concerns, and available informal and formal supports.
• Develop, implement, monitor, and update person-centered care and service plans in collaboration with clients, families, providers, and other members of the care team.
• Complete comprehensive, person-centered MnCHOICES assessments to identify functional, health, psychological, environmental, and social needs and determine eligibility for applicable long-term services and supports.
• Provide individuals with information regarding available services and supports to assist them in making informed choices regarding their care and living arrangements.
• Provide Relocation Service Coordination to eligible nursing facility residents seeking to transition to community-based settings.
• Assist clients with identifying and accessing appropriate housing, healthcare, transportation, home and community-based services, financial resources, and other supports necessary to maintain community living.
• Coordinate services with healthcare providers, health plans, nursing facilities, home and community-based service providers, family members, legal representatives, and other community partners.
• Conduct client visits and maintain required contact with individuals receiving case management and care coordination services.
• Monitor client health, safety, service utilization, and progress toward identified goals and make adjustments to service plans as needs change.
• Complete eligibility-related documentation, service authorizations, assessments, case notes, care plans, referrals, and other required records accurately and within established timelines.
• Maintain knowledge of applicable federal and state regulations, Minnesota Department of Human Services requirements, health plan requirements, county policies, and program guidelines.
• Utilize electronic assessment, case management, documentation, and communication systems in the performance of assigned duties.
• Maintain confidentiality of client information and comply with applicable data privacy requirements.
• Participate in interdisciplinary care planning, case consultation, team meetings, training, and professional development activities.
• Maintain required MnCHOICES certification and complete required recertification and continuing training.
• Other duties as assigned.

• Bachelor’s degree in Social Work or a closely related human services field required.
• Registered Nurse or Public Health Nurse.
• Two (2) years of related experience preferred, or an equivalent combination of education and experience.
• Valid driver’s license and reliable transportation required.
• Must pass a criminal background check and meet DHS requirements for working with vulnerable populations.

Skills and Abilities

• Knowledge of person-centered assessment, care planning, case management, and care coordination principles.
• Knowledge of or ability to learn Minnesota long-term services and supports, including Alternative Care, Elderly Waiver, MSC+, MSHO, MnCHOICES, and relocation services.
• Strong assessment and interviewing skills with the ability to identify client strengths, needs, risks, preferences, and goals.
• Ability to develop and coordinate individualized service plans that promote independence, safety, choice, and community living.
• Excellent verbal and written communication skills with the ability to communicate effectively with clients, families, providers, health plans, and community partners.
• Strong organizational and time management skills with the ability to manage multiple cases, deadlines, assessments, and program requirements simultaneously.
• High degree of accuracy and attention to detail when completing assessments, case documentation, service plans, authorizations, and other required records.
• Ability to complete documentation and required paperwork accurately and within established timelines.
• Proficiency with computers, electronic equipment, electronic assessment tools, case management systems, and standard office software.
• Ability to learn and effectively utilize MnCHOICES and other state, county, and health plan electronic systems.
• Ability to interpret and apply federal and state regulations, program requirements, health plan requirements, and agency policies.
• Strong critical-thinking and problem-solving skills with the ability to respond appropriately to changing client circumstances.
• Ability to work independently, prioritize responsibilities, and seek consultation when appropriate.
• Ability to collaborate effectively as part of an interdisciplinary team and coordinate services across multiple systems and providers.
• Ability to establish and maintain professional working relationships with individuals from diverse backgrounds and with varying levels of physical, cognitive, behavioral, and social needs.
• Commitment to person-centered, culturally responsive, and respectful service delivery.
• High level of discretion and ability to maintain confidentiality and comply with data privacy requirements.

Physical Requirements

• Ability to sit or stand for extended periods for meetings, care plan reviews, and documentation.
• Ability to occasionally lift and carry materials or files up to 25 pounds.
• Ability to travel for provider meetings, and training, including occasional overnight travel.
• Work may involve exposure to stressful or emotionally challenging situations.
• Must be able to perform essential duties with or without reasonable accommodation.

Kandiyohi County is and Equal Opportunity Employer.