LTSS Service Coordinator - Person-Centered Care Lead

Jobtailor; Vero Beach (FL); On-site; USD 42,000 - 62,000; Full time

Job summary

Jobtailor is seeking a Service Coordinator to manage a defined caseload in specialized programs. You will document preferences and goals via Person Centered Planning and build comprehensive PCSPs with backup plans.

Responsibilities include coordinating with Medical Directors, joining interdisciplinary rounds, and guiding LTSS, PH and BH needs with the member and care team.

Qualifications

• Requires a BA/BS and at least 2 years of experience with a social work agency.
• BA/BS field in health care related area preferred.
• Bilingual English/Spanish strongly preferred.
• LTSS, case management, social work or hospital discharge planning experience preferred.
• Education and experience may vary by state law and contract requirements.

Responsibilities

• Conduct service coordination functions for a defined caseload of individuals in specialized programs.
• Facilitate the Person Centered Planning process documenting member preferences, needs and goals.
• Conduct assessments and develop a PCSP and backup plan.
• Interface with Medical Directors and participate in interdisciplinary care rounds for an integrated care plan.
• Engage the member’s circle of support and manage PH/BH/LTSS needs.
• Document short and long-term service goals with the member’s care team.
• Identify members that would benefit from an alternative level of service or waiver programs.

Skills

Assessment Development

PCSP

Service Coordination

Interdisciplinary Care Collaboration

Goal Documentation

Bilingual English/Spanish

Education

BA/BS degree in health care related field

Job description

• Responsible for conducting service coordination functions for a defined caseload of individuals in specialized programs.
• In collaboration with the person supported, facilitates the Person Centered Planning process that documents the member’s preferences, needs and self-identified goals.
• Conducts assessments and develops a comprehensive Person Centered Support Plan (PCSP) and backup plan.
• Interfaces with Medical Directors and participates in interdisciplinary care rounds to support development of a fully integrated care plan.
• Engages the member’s circle of support and overall management of the individuals physical health (PH)/behavioral health (BH)/LTSS needs.
• Documents short and long-term service and support goals in collaboration with the member’s chosen care team that may include, caregivers, family, natural supports, service providers, and physicians.
• Identifies members that would benefit from an alternative level of service or other waiver programs.

Requirements

• Requires BA/BS degree and a minimum of 2 years of experience working with a social work agency; or any combination of education and experience which would provide an equivalent background.
• Specific education, years, and type of experience may be required based upon state law and contract requirements.
• BA/BS degree field of study in health care related field preferred.
• Bilingual in English/ Spanish strongly preferred.
• LTSS, case management, social work or hospital discharge planning experience preferred.

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Hard Skills

• Assessment Development
• Person Centered Support Plan (PCSP)
• Service Coordination
• Interdisciplinary Care Collaboration
• Goal Documentation

Soft Skills

• Communication
• Collaboration
• Engagement