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Locates, coordinates, directs, monitors, and assists in determining eligibility for social, medical, financial, and other services (formal or informal) to meet the needs of CAP clients. Completes psychosocial assessment, develops and revises the Plan of Care, prepares progress notes, work with the client and family, utilizing appropriate community resources, participates in discharge planning and in-service programs and acts as a consultant to other agency personnel, physicians, hospital staff, CAP providers, and Home Health agencies. Provides counseling, client and family advocacy, crisis intervention, community resources and education, information, and referral for community programs.
Job Responsibility:
Facilitate the entire service delivery process, beginning with the screening/assessment, including the identification and procurement of services, on-going monitoring of care and services, and the annual re-evaluation of the client’s needs and services
Obtains pertinent medical records to assist with completion of the SRF in a timely manner
Contacts and schedules the initial and Continued Need Review social work portion of the assessment according to CAP procedures
Develops and completes the assessment and Plan of Care based on information gathered at the initial assessment and at the CNR
Revises the Plan of Care and enters in the E-CAP system as client’s needs change, per NC Medicaid guidelines
Completes necessary forms/notices per NC Medicaid guidelines in the CAP patient files in Microsoft when changes occur and in initial assessment, or CNR
Locates and coordinates sources of help from within the family and community so that the burden of care is not exclusively bore by formal health and social agencies
Monitors the client’s situation to assure the quality of care
the continued appropriateness of the services
the correct level of care
and the continued appropriateness of CAP participation by reviewing provider documentation and claims
obtaining input from the client, family, and service providers
and personal observation
Coordinates with Medicaid income maintenance staff regarding the client’s eligibility for Medicaid and provides information to clients and/or families on meeting the client’s deductible
Makes home visits (per NC Medicaid guidelines) to assure services are appropriate according to the Plan of Care, to assure services are being rendered satisfactorily, to assure the home situation has not changed threatening the client’s health, safety, and well-being
Maintains cost effective service delivery by maintaining and utilizing knowledge of regulations and reimbursement requirements
Ensures all activities are provided in compliance with regulatory agencies and are properly collaborated with associated agencies or other care providers
Identifies, coordinates, and utilizes resources, as well as defining and documenting unmet needs and gaps in services
Collaborates with various disciplines to ensure a comprehensive and holistic approach to client care
Patiently and clearly provides information and assistance to inquiring clients/families, self, or agency referrals, in relation to CAP and home care services, routines, procedures, government programs, and community social and health agencies
Promptly investigates complaints and/or errors and takes corrective action when warranted
Accepts and reviews referrals to CAP in absence of Referral Coordinator, or designee
Participates in quarterly chart audit when necessary
Participates in staff and administrative conferences as directed
Maintains manuals, policies and procedures, and other required administrative records on an on-going basis
Participates as a resource person or instructor in orientation, in-service education, and community activities as requested
Participates on committees as appropriate
Performs local approval for CAP clients, CNR’s or revisions to Plan of Care when necessary (as deemed by CAP Director)
Documents Case Management in a running narrative in the CAP patient files and includes all contacts and activities related to clinical care
Demonstrates the knowledge and skills necessary to provide care appropriate to the age of the patients served
Meets competency requirements for position
Maintains a high degree of confidentiality at all times due to access to sensitive information
Maintains regular, predictable, consistent attendance and is flexible to meet the needs of the department
Follows all Medicare, Medicaid, and HIPAA regulations and requirements
Abides by all regulations, policies, procedures and standards
Performs other duties as assigned
Requirements:
Bachelors degree in social work, psychology or other related human services field
Knowledge of CAP/DA and CAP/C policies and procedures preferred
Experience in the evaluation and provision of long-term care services as well as working with children, aged, and disabled preferred
Excellent oral and written communication skills
Ability to multi-task under tight deadlines
Strong communication skills and interpersonal skills
Valid driver’s license and proof of insurance is required