Long Term Care Case Manager

Visiting Nurse and Hospice for VT & NH; Springfield (VT); On-site; USD 50,000 - 70,000; Full time

Job summary

A healthcare service provider in Vermont is seeking an LTC Case Manager to assist with care management for Medicaid clients. The role involves working collaboratively with community partners, resolving patient issues, and providing oversight of care services. Required qualifications include a Bachelor’s degree in social work or a related field and two years of healthcare experience. This position supports clients to live independently while ensuring access to necessary resources, contributing to positive health outcomes.

Qualifications

• Bachelor’s degree in social work or related field or LPN/RN.
• Two years of experience in health care or related field.

Responsibilities

• Provide case management to clients and families receiving long term care services.
• Assist with timely resolution of patient and family problems.
• Supervise and evaluate care provided by VNH PCAs.
• Educate and assist staff in using the Care Navigator database.

Skills

Case management

Assessment skills

Communication

Problem-solving

Education

Bachelor’s degree in social work or related field

LPN/RN

Tools

Care Navigator

Workbench One

Job description

Description

Position Summary: Assists with planning and implementation of VNH Long Term Care Service programs under the direction of the Long Term Care Service Director. The LTC Case Manager works with a caseload of Medicaid clients ensuring that they have access to resources that enable them to live successfully at home for as long as possible. The LTC Case Manager will work with community partners, OneCare Vermont or any other state or local programs/agencies, as determined by LTC Director.

LTC Case Managers, working as medical social worker assistants (assistant), will provide social services to VNH home health care patients as needed. Depending on the Case Manager’s qualifications, they may be required to provide skilled nursing or medical social worker assistant visits to clients in our Longitudinal Care Program or other Medicaid programs. These programs include (but are not limited to):

Choices for Care: This is a Medicaid program designed to support nursing home level of care clients in their homes for as long as possible.

Moderate Needs Care: This is a Medicaid program designed to support clients who are mostly independent but still need assistance with Instrumental Activities of Daily Living.

OneCare: OneCare Vermont is a provider-led Accountable Care Organization working to improve the health of Vermonters and lower health care costs. OneCare partners with health insurance companies, hospitals, independent medical practices, and community collaborators to offer interventions that lead to positive healthcare outcomes. OneCare gives doctors and other provider’s access to data, resources, and tools to improve patient health. Interventions focus on improving access to primary care and preventive medicine, thereby reducing ER visits and hospitalizations and leading to more effective management of chronic illness, mental illness and addiction.

Longitudinal Care Program: The Longitudinal Care Program (LCP) offers support and care management for High Risk patients who are no longer eligible for traditional home health care. Enrollment in the LCP allows for continued tele monitoring and RN case management with monthly home visits between skilled care episodes, and additional support from assistant and Community Health Workers as needed.

Principal Duties and Responsibilities

• Provide case management to clients and families receiving long term care services (Medicaid).
• Assist with timely resolution of patient and family problems by completing assessments including establishing goals and following through with referrals to community services as needed.
• Case management may include issues related to paraprofessional services, legal, financial, spiritual, emotional and/or interpersonal concerns.
• Supervise and evaluate care provided by VNH PCAs.
• Attend Community meetings as indicated-represent VNH in the community, establish collegial working relationship with community partners.
• Monitor and access Care Navigator, Workbench One, and Portal databases for OneCare program.
• Educate, assist and track staff to use the Care Navigator database, Develop Person Centered plans, Conduct Care Conferences, and Coordinate Care.
• Coordinate/provide services to the Longitudinal Care Pilot Program with VNA’s of Vermont.
• Knowledge of and access to Community Resources.
• Work collaboratively with VNH liaisons and staff across VNH programs.
• Data Entry for Care Navigator.
• Stewardship – support practices and communicates the VNH Mission and Statement of Values
• Problem Solving – interact with clients, resource agencies and co-workers in a positive and collaborative manner to achieve positive outcomes
• Planning and Organizing – collaborate with team members and community resources to achieve effective and achievable goals
• Quality – advocate for best outcomes
• Safety – promote and support self-management of healthy behaviors

Minimum Qualifications

• Bachelor’s degree in social work or related field or LPN/RN
• Two years of experience in health care or related field

Education

• Required: Bachelors or better in Social Work.

Equal Opportunity Employer
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