Case Management – Accept client referrals from and carry out Case Management responsibilities under the direction of the Lifelong Links Director.
· Accept referral and complete an intake per program guidelines.
· Complete a comprehensive assessment.
· Develop a service plan
· Implement services and provide ongoing monitoring
· Conduct Medicare Screen and applicable applications on all Medicare eligible clients requesting Material aid assistance
· Follow-up and reassessment of the client:
· Monthly client/collateral contact via telephone or in-person
· Annual face-to-face reassessment unless needed sooner due to client status change
· Client discharge/transfer
· Records and documentation in WellSky database to include:
o Intake form
o Comprehensive Assessment
o Mental Status Questionnaire
o Personal Health & Safety Plan
o Releases of Information
o Service Plan including signature page
o Record of referrals and requests
o Correspondence related to the case
o Case Notes documented in WellSky Journals and Activity & Referrals
o Enter Service Deliverables in WellSky for billable and non-billable activity
Options Counseling –
· Population includes 18-59 year olds with disabilities, Caregivers, individuals age 60+
· Utilize person-directed approach with the consumer to engage and discuss their goals.
· Assess needs, values, and preferences in order to discuss options.
· Explain pros and cons of various options and support persons to facilitate decision making.
· Develop person-directed action plan to support their decisions.
· Identify existing consumer resources and supports.
· Advocate for consumer decisions about services and supports.
· Identify available resources to address unmet needs.
· Make referrals or facilitate access to services, including assistance in completing applications or making phone calls.
· Enter all client interactions into the WellSky Database on a daily basis and maintain all client documentation.
· Provide follow up to determine how well the action plan is working or if it needs to be revised.
· Conduct Medicare Screen and other applications on Medicare eligible clients requesting Material aid assistance
· Make presentations to consumers, service-providers, and other community groups as requested and approved by your supervisor.
· Attend staff meetings and training events.
· Performs other duties as assigned.
· Inform USA certification required.

REQUIRED QUALIFICATIONS:

· Bachelor’s degree in a human services field
· License to practice as a registered nurse
· License to practice as a licensed practical nurse and four years of experience working in the areas of aging, disabilities, community health or hospital discharge planning; OR
· Bachelor’s degree and two years of experience working in the areas of aging, disabilities, community health or hospital discharge planning; OR
· Associate’s degree and four years of experience working in the areas of aging, disabilities, community health or hospital discharge planning;
· Must become trained and/or certified with Inform USA within 12 months and Adult/Child Mandatory Reporter within 6 months of employment.
· Must successfully complete the Person-Centered Counseling curriculum provided by the aging network.
Job Type: Full-time

Benefits:

• Dental insurance
• Employee assistance program
• Flexible spending account
• Health insurance
• Life insurance
• Retirement plan
• Vision insurance

Medical Specialty:

• Home Health

Schedule:

• 8 hour shift

Work Location: In perso

Please refer the Job description for details