Responsible for determining and monitoring long-term care needs for eligible clients over 65 through a participant-centered approach. This includes conducting comprehensive assessments, developing service plans, and coordinating cost-effective home and community-based services.
Requirements summary
Requires a bachelor's degree in human services, education, health/medical, or a Nebraska RN license with at least two years of professional experience in long-term care or case management. Must possess a valid driver's license, reliable vehicle, and proficiency in Microsoft Office.
Job Title ENOA, Services Coordinator Hours Required 40 Job Description and Hours Responsible for determining and monitoring the appropriate long term care needs of financially eligible clients over the age of 65 who are requesting or receiving assistance through home and community based services.
Responsible for coordinating home and community based services to eligible participants by identifying their strengths and needs and incorporating formal and informal supports through a participant-centered approach to service planning and delivery.
Responsible for completion of a comprehensive assessment to identify client strengths and needs.
Responsible for providing participants with choices for safe independent living options and consumer-directed services that are cost efficient.
Essential job functions: 1.
Must report to work as scheduled on a regular and reliable basis.
2.
Successfully complete all required pre-service orientation and training.
3.
Must insure confidentiality of all client information and act in accordance with HIPAA regulations.
4.
Ability to understand and comply with various laws, rules, regulations, policies and guidelines as they pertain to both ENOA and ENHSA.
5.
Ability to communicate clearly, both orally and in writing and be able to establish effective working relationships with many different people, ranging from directors, coordinators, professionals, community representatives, support staff and the general public.
6.
Be a strong team player with positive attitude toward working with staff and with clients and their formal and informal support systems.
7.
Must have good computer skills with general knowledge of Microsoft office and have the ability to learn other computer systems.
8.
Work with established standards for service coordination and employee’s professional discipline.
9.
Basic knowledge of applicable state and federal laws, policies and regulations as they relate to the Nebraska Medicaid Program.
10.
Knowledge of medical and psychiatric diagnoses, prognoses, needs, and expected outcome goals.
11.
Ability to establish positive relationships, promote client/family autonomy while using a participant-centered approach to the service coordination process.
12.
Assessment
A comprehensive assessment is the vital first step in the service coordination process. This assessment is the process of systematically and comprehensively identifying the strengths and limitations that influence the participant/client’s functional capacity. The assessment process includes a face to face interview with participant/client in their home environment, observations, and collateral contacts to confirm the Nursing Facility level of care determination and proceeds accordingly. The service coordinator uses a participant centered process in which the participant/client identifies strengths, needs, priorities, resources, and barriers. Each participant/client needs to be reassessed at least annually and upon any major biopsycho-social changes that influence their functional ability and safety. 13.
Planning
The plan of services and supports is a collaborative, written document that is prepared with the participant/client and services coordinator. It is based on the findings from the comprehensive assessment, collateral data and the participant’s/client’s preferences.
The plan of services and supports document includes: problem statements converted to measurable outcome goals, strengths, intervention/service objectives, units of service (formal and informal), timeframes and providers/contacts. The Service Coordinator and the participant decide on the level of services coordination and determine the role of the Services Coordinator and the participant in the plan implementation. 14.
Implementation
The Services Coordinator and the participant identify formal providers and informal supports with focus upon participant preference and cost effectiveness. 15.
Coordination
Services and care arrangements require a Service Coordinator to be the broker of high quality and cost effective services. A Service Coordinator must develop and maintain rapport and communications with the participant/family and caregiver/s so that important information regarding delivery of services and products impacting on the goals and outcome of the plan can be disclosed. Maintaining professional rapport and communication with the members of the team is essential so the plan can be discussed objectively, problems identified, and adjustments made to the plan as needed. The Service Coordinator for the participant is the “team leader” for said participant and initiates communication with other disciplines as needed for appropriate planning (e.g. joint assessments, care planning meetings, external professionals). 16.
Monitoring
Careful follow-up that tracks whether or not the service was provided as requested and if it was satisfying; monitoring must occur in a timely manner via direct and telephone contact. Maintain regular communication with all providers delivering care, services, and products to the participant for quality assurance purposes. Ascertain that the outcomes of the plan are appropriate, understood, documented, and being met. Advise the providers of adjustments or revisions to be made in the plan. 17.
Evaluation
Determining if the outcome goals and service objectives in the plan of services and supports produce beneficial results to the client and agency. This may include gathering statistical information to evaluate both client level outcomes and service utilization outcomes. 18.
Advocacy
The Service Coordinator provides the client with information and training that promotes self-sufficiency. Advocacy is a process that occurs throughout the service coordination process and is an essential element to ensure participant centered care and empowerment. 19. Must have a valid driver’s license, reliable vehicle and state required car insurance.
OTHER
JOB
DUTIES: 1. Other job-related duties as assigned by the Division Director.
Education,
Training
AND
EXPERIENCE: 1. Baccalaureate degree in the field of human services, education or health/medical or Registered Nurse, currently licensed in Nebraska and a minimum of two years professional experience in long-term care, gerontology, rehabilitation, health/safety case management, children with special health care needs or health and medical. 2. Previous work experience and technical understanding of the psycho-physiological traits of aging and the older adult preferred.
SKILLS
AND
ABILITIES: 1. Possess good judgment, organizational ability and initiative. 2. Be detail oriented, flexible, multi-tasked, discrete and decisive with a strong ability to prioritize tasks and use critical thinking skills. 3. Independently organize and prioritize workflow, ensuring timeliness and professionalism, in all functions. 4. Familiarity and ability to drive through the five county geographic service area in a variety of road conditions. 5. Have a high standard of integrity and knowledge of professional ethics 6. Ability to work independently and complete required paperwork within specified timeframes. 7. Must have good computer and typing skills with general knowledge of Microsoft office and have the ability to learn other computer systems. 8. Must have the ability to use office equipment; such as fax, scanner, copier, printer, and other equipment as needed.
Physical
DEMANDS
AND
WORKING
CONDITIONS: 1. Must be able to tolerate a variety of working environments.
Note
This job description is intended to convey information essential to understanding the scope of the job and the general nature and level of work performed by jobholders within this job. But, this job description is not intended to be an inclusive list of qualifications, skills, efforts, duties, responsibilities or working conditions associated with the position and may be subject to revision. #INDLP ENOA’s role is to ensure older adults within its region have access to a continuum of services that enable them to remain active, independent and in their own homes for as long as possible. ENOA serves as a gateway to aging services that already exist in the community and also operates its own programs that fill previously unmet needs in the five-county area. Through our nutrition programs, care management services, volunteer opportunities and community services, ENOA’s goal is to enhance the lives of older Nebraskans who live within our service area. A further mission of the Eastern Nebraska Office on Aging is to continually assess the needs of older individuals and their families and to adapt our programs to meet changing needs. By creating unique programs that fill gaps in service, ENOA helps older Nebraskans to live more independently, to live with dignity, and to remain for as long as possible in their own homes.
