Elderly Services Program (ESP) Care Manager and Consumer Directed Care Specialist

Provide care management for clients of the Elderly Services Program (ESP), including completing assessments to determine client need, develop service plans, make collateral referrals, coordinate services and ongoing client status, conduct client visits including in home and/or facilities.  Provide identified clients assistance in applying for Consumer Directed Care (CDC), including completing forms, providing information to Acumen, following up with client and Care Manager (CM), and coordinating start of services with Acumen, client and CM.  

Care Manager

• Maintain Client Caseload:
  • Assess client referrals for program eligibility according to program policy and procedures; enroll eligible individuals
  • Develop individualized service plans in collaboration with client and/or caregiver that includes community resources as well as ESP services
  • Provide information and referral as needed
  • Inform clients of rights and responsibilities
  • Monitor service plan costs to ensure we adhere to cost caps, per procedure
  • Secure and monitor services to ensure quality of care to support the health and safety of the participants
  • Maintain the client contact schedule of required interventions (phone or home visits) to assess and verify the service plan; identify any problems in service delivery and assess for any changes in client status, conditions or needs; provide support and assistance as needed and assure ongoing eligibility
  • Maintain ongoing contact and open communication with caregivers, family members, friends and other sources of informal support as appropriate
  • Work with clients, service providers and others involved in the client’s plan of care in mutual problem solving and coordination of care as needed
  • Complete review of income and medical expenses to determine client co-payment amount if applicable. Monitor client’s co-payment status
  • Assist client/caregiver with discharge planning as appropriate
  • Follow policy and procedure for processing client appeals and participate in appeal proceedings as required; disenroll clients who no longer meet eligibility requirements in accordance with policy and procedures

CDC Specialist

• Receive client referrals from CM staff and complete enrollment into the CDC program according to program policy and procedure.
• Complete required CDC paperwork with client/Authorized Representative (AR) and or Employee and send to service provider for approval. If service provider requests corrections those corrections will be obtained and forwarded to service provider. 
• Complete home visits, virtual meetings or phone calls in order to complete CDC enrollment paperwork
• Maintain ongoing contact with client, caregiver, family members or friends as appropriate.
• Maintain ongoing and open communication with service provider and Care Manager.
• Assist client/AR and employer to determine tasks to be completed, number of hours of services and rate of pay for the employee.                                    
• Provide appropriate documentation to COA for approval.
• Add CDC authorization to care plan once service provider gives good to go date.

• Administrative:
  • Maintain accurate and confidential computer record of client activity using care management software
  • Adhere to confidentiality policy and HIPAA protocol as related to all client information/interactions
  • Follow-up on reported incidents and health and safety issues. Complete incident reports and/or complaint form as necessary
  • Participate in the PQI process as directed by supervisor or manager
  • Cooperate with care management team to assure adequate and appropriate care management coverage of all agency clients.
  • Promote a positive community image at all times
• Meetings:
  • Attend required program and agency trainings and meetings
  • Participate in case conferences
  • Attend professional meetings, workshops, seminars as appropriate
  • All other duties as assigned and/or appropriate to the position.

Education and Licenses or other required certifications: Licensed Social Worker OR Registered Nurse OR Bachelor’s prepared degree in social work, gerontology or related field.  Must have an acceptable criminal records check.  Must have valid drivers license, insurance, reliable transportation and ability to complete home visits.

Experience: Prefer at least one year experience in geriatrics, case management, long-term care, home health or medical social work.

Specialized knowledge, skills, or abilities: Must possess excellent communication and organizational skills. Must be proficient in basic computer applications.