This full-time position, is based at Silver Birch in Mishawaka. You will be responsible for providing information, referrals, and options to individuals when they access the Aging and Disability Resource Center and is responsible for addressing client needs and managing the coordination of individuals’ on-going care, with a focus on serving individuals applying for the Medicaid Waiver for Assisted Living services and individuals residing in Assisted Living communities with services funded by the Medicaid Waiver. This position’s primary functions include initiating Assisted Living services under the A & D and TBI Medicaid Waivers and performing on-going care management functions for Waiver individuals residing in Assisted Living communities. This position supports the organization’s mission to promote independence and empower individuals served, while advocating for the individuals when needed.
ESSENTIAL DUTIES include the following. Other duties may be assigned.
- Meet with individuals, families, and caregivers to provide comprehensive assessment of needs and facilitate Options Counseling. Identify the individual’s strengths, values, and preferences. Identify resources available to individual including their circle of support (formal and informal supports) and community organizations.
- Screen individuals for potential eligibility for funding sources and programs. Determine eligibility for ongoing home and community based services.
- Assist in accessing home and community based services that would meet identified Take action to initiate appropriate services. Develop initial service plan and submit level of care documentation. Update, reduce, and terminate care plans/services based on the individual’s current needs. Follow-up to ensure services are meeting the individual’s needs. Use resources wisely, ensuring services are cost-effective, appropriate, and needed.
- Assist individual with completing Medicaid application, gathering and submitting required documents, attending application interview, and follow-up until eligibility is determined by the Division of Family Resources.
- Contact individual’s preferred vendors to secure provider.
- Complete PASRR Level 1, Level of Care Tools, and Options Counseling, as defined by the Division of Aging. Complete intake appointments.
- Complete required documentation and reports in a concise and timely manner.
- Coordinate work flow and coverage with other agency staff members.
- Attend staff meetings and training sessions as scheduled.
- Train agency staff members.
- Maintain case management standards and meet task timelines. Contribute actively to the outcomes of the team and meet team expectations.
- Alert Team Leader when consultation is required. Work with Team Leader and other disciplines when additional consultation is required.
- Contribute to an environment that supports our mission of individual service and care.
- Abide by all agency Personnel Policies and Code of Ethics.
- Apply person-centered care philosophy and “needs based” service model.
- Provide excellent customer service. Serve individuals in a manner that is empowering, encourages, independence, is patient, compassionate, and person-centered.
- Advocate on behalf of the individual’s needs.
A Community Living Specialist is responsible for performing interviews with inquirers and with established individuals to assess their needs, determine eligibility for programs, make recommendations for community services or alternate living arrangements, seek out resources to meet needs, determine appropriateness of services, determine level of care, and manage Action Plans and Plans of Care, all based on the needs of the individual. A Community Living Specialist is responsible for performing ongoing activities that ensure access to all services from which an individual might benefit. Additionally, Community Living Specialists maintain ongoing case records and make recommendations for community services or alternate living arrangements based on the needs of the individual in their care. In keeping with a person-centered care model, the Community Living Specialist recognizes each person’s unique needs and works with formal and informal supports to meet needs. Community Living Specialists must be well-versed in evaluating needs based on supporting independence and empowerment and must understand the requirements of various funding sources. It is essential that work is completed in a quality and timely manner, efficiently and accurate, in accordance with program standards and guidelines. It is sometimes necessary to use some analysis and judgment in determining the best procedure to follow or how to best communicate information to caregivers and inquirers who may be in stressful situations.
EDUCATION AND/OR EXPERIENCE REQUIREMENTS
Bachelor’s degree (BA or BS) from an accredited four-year college or university in social work, psychology, gerontology, counseling; or a license as a registered nurse with one year of experience in human services; or a bachelor’s degree in any other field with a minimum of two years, full-time direct services experience with the elderly or disabled persons. This experience must include assessment, plan of care development, implementation, and monitoring. Or applicant may have a master’s degree in a related field to substitute for the required experience. (Division of Aging Application for 1915 (c) HCBS Waiver: IN0201.R06.00-July 01, 2018)
- Maintain ongoing Case Management certification.
KNOWLEDGE. SKILLS. AND ABILITIES REQUIRED
- A specialized knowledge of principles and practices developed through relevant experience after a baccalaureate education or nursing equivalent.
- Ability to assess an individual’s specific needs and plan solutions; to understand, empathize, and relate to behavior of individuals; to certify initial and ongoing eligibility for programs and services being authorized on the service plan.
- Ability to assess specific needs both in person & on telephone; ability to develop rapport quickly.
- Knowledge of options, funding sources, services, resources, and information available through REAL Services and in the Knowledge of in-home and community-based services, funding sources, and eligibility. Understands basics of Medicare, Medicaid, Private insurance, other benefits, and other payment options.
- Excellent communication skills, both orally and in writing with good interviewing skills. Ability to tactfully and diplomatically convey decisions to a client and their family.
- Ability to organize information, prioritize assignments, complete tasks in a timely manner, and to use sound judgment.
- Ability and attitude to work productively independently and cooperatively and relate to the needs of the staff, the clients, and the agency.
- Ability to follow instructions and procedures, to interpret information, and to complete assigned tasks in accurate, concise, and detailed manner.
- Ability to operate office equipment, including but not limited to phone, facsimile, copy machines, and computer equipment.
- Ability to learn State- approved software and other computer programs as relevant to successful completion of tasks. Ability to use Microsoft Word, Access, and Excel. Ability to use iPad for care management assessment functions and other related tasks.
DIFFICULTY OF WORK
The work demands sound judgment be exercised in selecting the most tactful approach in communicating with the client and the client’s family. All documentation must be accurate and timely. The work is repetitive in nature inasmuch as the same tools, forms, and procedures are utilized routinely, but does involve variables and considerations when dealing with diverse situations and when preparing a care plan or considering alternatives in individual cases. Travel independently within Elkhart, Kosciusko, LaPorte, Marshall, and St. Joseph counties in Indiana is required.
PERSONAL WORKING RELATIONSHIPS
- With various clients and their families, and caregivers;
- With community professionals and agencies;
- With providers;
- With Assisted Living staff, serving as liaison for the Assisted Living community and the Agency;
- With Agency staff members.
WORKING CONDITIONS AND PHYSICAL DEMANDS
The physical demands and work environment described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is usually seated, standing, or walking at will in a typical office setting. Very limited physical effort required.
- Valid driver’s license and a dependable vehicle required.
- Regular and reoccurring travel to meetings, training, and client visits.
CONDITIONS OF EMPLOYMENT
- Must learn IRIS or any other resource database utilized in the ADRC;
- Must learn the State approved case management systems;
- Successful candidate must submit to a pre-employment drug screening, National Sex Offender registry, a limited criminal history, and a driver check.
- Proof of educational credentials is required at time of employment.
- This position has a 6 month probationary period.
- Must sign non-compete clause.