Job Description

Care Coordination Services

• Performs care coordination services for assigned recipients who are eligible for home health services (Home Health Visits, PPEC, Personal Care Services and/or Private Duty Nursing Services etc. based on contract requirements).
• Uses discretion to approve/validate UR or forward to 2nd level reviewer. Provides first level utilization review for all inpatient and outpatient services requiring authorization: Prospective Review Urgent/Non-urgent, Concurrent Review and Retrospective Review.
• Completes prior authorizations as appropriate in a timely manner.

Initial Assessment and Planning

• Conducts an initial survey to recommend appropriate (home health assessment) for the recipient, unless this has already been done during the current fiscal year.
• Conducts a home and/or PPEC visit as needed or if contract requirement.
• Schedules and convenes initial face-to-face meeting in the recipient’s home and/or PPEC comprised of the recipient (if able) and the parent or legal guardian.
• Assesses, plans, implements, monitors and evaluates the options and services required to meet the recipient’s health care needs.

Documentation and Communication

• Documents recipient’s assessment findings, actions, and outcomes.
• Documents all communication, interventions and follow up tasks in the Care Coordination System within one (1) business day of each intervention and/or encounter.

Collaboration and Coordination

• Identifies patient care issues and makes recommendations on patient care issues.
• Collaborates with the parent or legal guardian and healthcare team to arrange for identified home care needs.

Plan of Care Management

• Responsible for maintaining regular monthly contact (telephonically or face-to-face) with the recipient and the recipient’s parent or legal guardian for purpose of updating Plan of Care (POC), resolving issues and identifying additional issues.

Multidisciplinary Team Engagement

• As part of the multidisciplinary team, regularly meets with the team and contributes to the development of a comprehensive plan of care based on the needs of the recipient and recipient’s parent or legal guardian.
• Evaluates and modifies recipient’s plan of care as needed. Regularly communicates changes to the recipient’s parent or legal guardian, healthcare team, and other agencies involved in the recipient’s care.

Caseload and Community Resource Management

• Monitors assigned caseload eligibility status on a monthly basis, based on their status in MMIS.
• Completes a Staffing Tool (Freedom of Choice) any time a parent or legal guardian expresses the desire to reconsider a recipient’s placement into a Skilled Nursing Facility.
• Follows guidelines for additional required calls and visits for Skilled Nursing Facility (SNF) transitions to community settings for six (6) months.

Community Engagement

• Functions as a resource to the community.

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