Overview Fairview Partners (FVP) provides high intensity care coordination and case management for seniors and other at-risk populations living in a variety of care settings throughout the 11-county metro area. The FVP Social Worker (SW) Care Coordinator provides coordination across all settings of care and performs the functions of case management which include, but are not limited to: assessment, care planning, service coordination and referral, transition management, utilization management and quality assurance. The care coordinator promotes holistic, high quality and cost-effective care with the goal of keeping seniors in the most independent care setting possible. Care coordination for the FVP population is delivered via partnerships with managed care organizations (MCO) and must adhere to regulations set forth by the MCOs, the Minnesota Department of Human Services (DHS), the Minnesota Department of Health (MDH) and the Centers for Medicare and Medicaid Services (CMS). This position will serve Fairview Partners members in St. Paul and its surrounding suburbs in the eastern Twin Cities metro area. Responsibilities Job Description Job Expectations: Assessment Conducts annual Health Risk Assessment and scheduled follow-up assessments according to MCO, Minnesota Department of Human Services (DHS) and Centers for Medicare & Medicaid Services (CMS) guidelines Performs additional clinical assessments specific to the population being served per professional scope of practice and license Assesses eligibility for State Plan Personal Care Attendant services during HRA, as appropriate Performs pre-admission screening annually and upon transfer to skilled nursing facilities Care Planning Creates person-centered care plan with member including realistic goal-setting and follow-up plan for measuring goal progress Promotes informed choice of benefits, services and health care providers Prioritizes member’s safety and risk mitigation Implementation of care plan via resource referral and communication with interdisciplinary care team Evaluation of care plan including outcome measures and goal achievement Coordination of Medicare and Medicaid Benefits & Services Maintains knowledge of Medicare and Minnesota Medical Assistance health care benefits Provides case management of Elderly Waiver program benefits and services Maintains knowledge of long-term services and supports (LTSS) policy and eligibility criteria Maintains members’ eligibility data in the Minnesota Medicaid Information System (MMIS) Member of Interdisciplinary Team/Facilitator of Communication Actively communicates with other care team members Attends departmental case conferences as requested Attends care conferences Convenes interdisciplinary team members, as needed, for complex case management Consults with FVP Nurse Care Coordinator for members with complex health care needs Coordinates with other agencies or professionals involved in members’ care, including but not limited to: waiver program case managers, Mental Health Targeted Case Managers, Adult Protection workers, state Ombudsman representatives and county financial workers Transition Management: Actively manages member transitions and communicates across settings to ensure continuity of care Completes required documentation for transitions of care as required by CMS and DHS Attends transitional care conferences Provides discharge follow-up and modification of care plans to ensure members can successfully manage care needs upon return to original care setting Assists members with planning and resources in transitions to new care levels or living settings Additional Responsibilities Preventative Health Education: Provides education on preventative health measures, as appropriate, for member’s age and health status; promotes managed care health promotion program resources Care planning and service referral for members with complex psychosocial or behavioral health needs Mandated Reporting: Reports maltreatment under the Minnesota Vulnerable Adults Act; understands a member’s right to autonomy and self-determination and recognizes reportable risk Advance Care Planning: Maintains knowledge of advance care planning principles; follows Fairview’s system advance care planning policies and procedures to promote a culture of informed health care decision-making that honors a member’s goals, values and beliefs Quality: Carries out activities to support the achievement of outcome measures for the Fairview system, Health Plans, DHS and CMS Additionally, the care coordinator maintains professional boundaries and provides culturally appropriate care. The care coordinator is committed to ongoing professional learning and continually improves his or her practice by attending professional conferences and continuing education activities related to case management and care coordination. Organization Expectations, as applicable: Demonstrates ability to provide care or service adjusting approaches to reflect developmental level and cultural differences of population served Partners with patient care giver in care/decision making. Communicates in a respective manner. Ensures a safe, secure environment. Individualizes plan of care to meet patient needs. Modifies clinical interventions based on population served. Provides patient education based on as assessment of learning needs of patient/care giver. Fulfills all organizational requirements Completes all required learning relevant to the role Complies with all relevant laws, regulation and policies Performs other duties as assigned Qualifications Required Education Bachelor’s degree in Social Work Experience Two years of experience in medical social work, case management/care coordination Critical thinking and ability to work with patients with complex health and psychosocial issues a must License/Certification/Registration Current Minnesota Social Work license in good standing Preferred Experience Three to five years of experience in medical social work or case management/care coordination; experience working with geriatric population; strong knowledge of managed care programs, long-term services and supports, Medicare and Medicaid benefits and senior care industry License/Certification/Registration Current Minnesota Social Work license in good standing Certification in case management Additional Requirements (must be obtained or completed within a period of time): Basic computing skills including keyboarding, Microsoft Word, Outlook and Excel and Adobe Acrobat; demonstrated proficiency with electronic medical record systems; excellent written and verbal communication skills EEO Statement EEO/AA Employer/Vet/Disabled: All qualified applicants will receive consideration without regard to any lawfully protected status