Care Coordinator

Provide comprehensive case management services for seniors and individuals living with disabilities that are enrolled into MSHO/MSC+ state health plans. 

Qualifications for the position include:

• BACHELOR'S DEGREE IN SOCIAL WORK REQUIRED
• LICENSURE AS A SOCIAL WORKER THROUGH THE MINNESOTA BOARD OF SOCIAL WORK (LSW, LGSW, LISW, OR LICSW)
• Supervised social work and/or case management experience in the field of aging/gerontology preferred.
• Experience with Medical Assistance or Elderly Waiver is a plus.
• Knowledge of county programs and community-based services preferred.
• Experience working with refugee populations and non-English speaking clients is a plus.
• Able to work well in a multi-disciplinary team.
• Valid driver's license and a personal vehicle to use for agency business.
• MUST LIVE IN COMMUTABLE DISTANCE TO SAINT PAUL, MN FOR MEETINGS AND TRAININGS.

 As a care coordinator, you will:

1. Maintain a caseload of clients who are 65 and older.. Care Coordinatorsprimarily work with clients on the Elderly Waiver.
2. Meet with clients in their homes to complete assessments on an annual basis. Assessments are currently remote as we navigate COVID situation.
3. Complete initial and annual psychosocial assessment to identify presenting problem(s) and gather pertinent history. Primary goal of assessment is to keep clients living independently in their preferred setting with appropriate services and supports.
4. Set up and maintain home care-based services
5. Create unique care plan based on assessment/reassessment. Identify needs, goals, and interventions. Update care plan as needed based on observation and conversation.
6. Include the family/others from the client's support system in the development and ongoing implementation of the plan, and update care plan as needed based on observation/conversation.
7. Collaborate with medical professionals and care teams
8. Make referrals to other agencies or resources as appropriate.
9. Assist with transitions and discharge planning when a client is returning home from the hospital or nursing home.
10. Complete detailed and timely case notes on every interaction with clients and families/professionals involved in their care.
11. Participate in team meetings and case consultation discussions.
12. Participate in health plan and DHS trainings and meetings
13. Participate in committees (JFS, community partnerships) as assigned.
14. Provide coverage for intake as needed. Provide backup coverage for other members of the senior service department

 OTHER FUNCTIONS:

1. Attend agency staff meetings, staff development activities and special events;
2. Adhere to NASW Code of Ethics, personnel practices and other designated policies and procedures.
3. Follow agency procedures and maintain complete and professional case records. Complete necessary tasks in a prompt and efficient manner.
4. Pursue professional growth through reading, workshops and other learning opportunities directly relevant to the above described job responsibilities.
5. Carry out regulations of assigned programs;
6. Back-up other staff as necessary;
7. Perform other job duties as required.