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Senior Resources of West Michigan in Norton Shores, MI is seeking a Targeted Care Management Supports Coordinator to assess and arrange services for older adults on the TCM program. This full-time role focuses on in-home and community supports, coordinating with nurses to implement approved care plans and ensure smooth transitions between services.
The position requires a Bachelor's degree in Human Services or CHW Certification and 2–3 years of home care experience, with preference for at least
To provide a comprehensive and coordinated system of services designed to promote the independence and dignity of older persons and their families in Muskegon, Oceana, and Ottawa counties - a mission compelling us to focus on older persons in greatest need and to advocate for all.
Assess, evaluate, and arrange services for older adults on the Targeted Care Management (TCM) Program who are 60 years of age or older, who are in need of in-home services, community services, or have another need that warrants a comprehensive assessment.
Provide a comprehensive assessment of participants referred through pre-screen/intake. Includes evaluation of needs, available resources, existing services and arrangement for additional support as identified through assessment. Support services may include Senior Resources Grant, Medicaid chore services and other community programs. Notify participant and contracted vendor of approved service plan. Complete required paperwork for billing purposes.
Offer all assessed participants choice of services and providers. Allow for patient-centered care planning.
Link people deemed ineligible to appropriate service agencies and community resources.
Maintain files and pertinent program records in an efficient and timely manner according to program guidelines.
Reassess participant’s needs through ongoing face-to-face reassessments every 90 or 180 days.
Complete monthly visits as required for TCM, including documents for Medicaid spend-down as indicated.
Collaborate closely with Registered Nurses in the Targeted Care Management program to coordinate and support participant care. Provide assistance, education, and understanding for participants in the areas of Medicaid, Medicare, Social Security Insurance, Food Assistance Program, and other public benefit programs. Assist in completing forms as needed.
Establish a close relationship with supports coordinators to provide smooth transition of care between service programs for participants based on their needs and level of care.
Advocate for older adults.
Attend periodic in-services, professional conferences, and seminars.
Maintain participant confidentiality.
Perform all other duties as assigned.
Bachelor's degree in a Human Services field, a Community Health Worker Certification or two to three years of experience in a home care setting. Minimum of one-year home care experience preferred. Experience working with older and/or disabled adults preferred.