Care Coordinator (Case Management)
Personal Wellness and Care Coordinator -Envisage/Encore on the Lake
Summary:
To provide an individualized plan of care for each Envisage and Encore on the Lake (Encore) Member using effective and efficient case management techniques.
To maintain a professional relationship with Members, physicians, Extended Care Partners and all other disciplines involved in the Member's care.
To continually update clinical assessment skills and knowledge of available resources for older adults.
To serve as a wellness coach to help people age successfully in the place they call home.
Essential Duties and Responsibilities include:
Identifies and suggests innovative approaches and helps implement performance improvement opportunities.
Complies with Presbyterian SeniorCare Network policy and procedure in accordance with governing laws, regulations, regulatory agencies, accreditation bodies and facility standards.
Consistently demonstrates individual and team behavior that supports our person-centered culture, the Woodside philosophy, and the mission, values and behavior standards of the Network.
Maintains confidentiality.
Other duties may be assigned.
Manage a complex caseload of Envisage and Encore Members and Consultative Care Members to include:
1) Conducts Psychosocial Assessments including cognitive screening and functional status; 2) Completes Risk Assessments as applicable; 3) Develops service plan (Envisage only, N/A for Encore); 4) Collaborates with provider(s) to create care plan for member 5) Arranges and coordinates services based on Envisage plan benefits and Encore Member Agreement; 6) Educates and counsels Members and support system to meet goals of service plan; 7) Collaborates with Member's medical team as appropriate; 8) Refers, monitors, and evaluates provision of care by credentialed Extended Care Partner; 9) Reassesses Member's needs due to changes in health, behavior, or functional status; 10) Facilitates transition to and from a higher level of care, as necessary; 11) Facilitates and coordinates palliative and hospice care Holds regular, posted office hours to be available by appointment and walk-in for consultation with Encore members regarding any of the above items.
Conducts home/virtual visits to Envisage Members and maintains frequency of contacts as defined by Envisage Member Agreement.
Conducts individualized visits to Encore members in their living space, frequency of contacts as defined by need.
Maintains detailed records of member information and activity in electronic health record.
Reviews accurate and timely billing records for Envisage Member caseload each month.
Participates in the Envisage on-call rotation for non-business hours including weekends and holidays.
Participates in Masterpiece Living training and utilizes techniques learned to provide wellness coaching for the four quadrants of wellness:
Physical, Intellectual, Social, and Peace & Fulfillment.
Collaborates with service line leadership to plan, develop, and/or present continuing education programming that may include topics related to chronic disease management, wellness, nutrition, cognition, and fall prevention.
Tracks utilization of hospitalization, rehab, Skilled Nursing Facility, Assisted Living Facility and private duty on a monthly basis.
Collaborates with extended family/POA as necessary.
Represents Envisage and/or Encore at professional meetings, sales events, networking opportunities, community organization meetings, etc.
Maintains up-to-date files on resources available in the community for older adults.
Other tasks as assigned by the Executive Director, Envisage.
Supervisory
Responsibilities:
This job has no supervisory responsibilities.
Qualifications:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.
The requirements listed below are representative of the knowledge, skill, and/or ability required.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education and/or
Experience:
At least two years experience in case management.
Computer Skills:
To perform this job successfully, an individual should have knowledge of Contact Management systems; Internet software; Spreadsheet and Word Processing software and virtual meeting platforms.
Certificates, Licenses, Registrations:
Valid Driver's License Access to a registered and insured vehicle for frequent and regular travel between Members' homes and professional offices.
Other Skills and Abilities:
Experience in case management or related field with older adults, including demonstrated skills in assessment, planning, evaluating plans of care, organizing and maintaining detailed filing systems; familiarity with updated clinical assessment methods and community resources; an understanding of reimbursement criteria for Medicare and Medicaid; and excellent interpersonal skills with demonstrated ability to interact and communicate effectively with Members, families, staff, providers, professional community and others.
Physical Demands:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is regularly required to talk or hear.
The employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel; reach with hands and arms and taste or smell.
The employee must occasionally lift and/or move up to 10 pounds.
Specific vision abilities required by this job include close vision and distance vision.
Work Environment:
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Ability to travel using personal vehicle to Members' homes and professional offices in Allegheny, Armstrong, Beaver, Butler, Washington and Westmoreland counties.
The noise level in the work environment is usually moderate Recommended Skills Assisted Living Billing Case Management Clinical Works Coaching And Mentoring Communication Estimated Salary: $20 to $28 per hour based on qualifications.
Summary:
To provide an individualized plan of care for each Envisage and Encore on the Lake (Encore) Member using effective and efficient case management techniques.
To maintain a professional relationship with Members, physicians, Extended Care Partners and all other disciplines involved in the Member's care.
To continually update clinical assessment skills and knowledge of available resources for older adults.
To serve as a wellness coach to help people age successfully in the place they call home.
Essential Duties and Responsibilities include:
Identifies and suggests innovative approaches and helps implement performance improvement opportunities.
Complies with Presbyterian SeniorCare Network policy and procedure in accordance with governing laws, regulations, regulatory agencies, accreditation bodies and facility standards.
Consistently demonstrates individual and team behavior that supports our person-centered culture, the Woodside philosophy, and the mission, values and behavior standards of the Network.
Maintains confidentiality.
Other duties may be assigned.
Manage a complex caseload of Envisage and Encore Members and Consultative Care Members to include:
1) Conducts Psychosocial Assessments including cognitive screening and functional status; 2) Completes Risk Assessments as applicable; 3) Develops service plan (Envisage only, N/A for Encore); 4) Collaborates with provider(s) to create care plan for member 5) Arranges and coordinates services based on Envisage plan benefits and Encore Member Agreement; 6) Educates and counsels Members and support system to meet goals of service plan; 7) Collaborates with Member's medical team as appropriate; 8) Refers, monitors, and evaluates provision of care by credentialed Extended Care Partner; 9) Reassesses Member's needs due to changes in health, behavior, or functional status; 10) Facilitates transition to and from a higher level of care, as necessary; 11) Facilitates and coordinates palliative and hospice care Holds regular, posted office hours to be available by appointment and walk-in for consultation with Encore members regarding any of the above items.
Conducts home/virtual visits to Envisage Members and maintains frequency of contacts as defined by Envisage Member Agreement.
Conducts individualized visits to Encore members in their living space, frequency of contacts as defined by need.
Maintains detailed records of member information and activity in electronic health record.
Reviews accurate and timely billing records for Envisage Member caseload each month.
Participates in the Envisage on-call rotation for non-business hours including weekends and holidays.
Participates in Masterpiece Living training and utilizes techniques learned to provide wellness coaching for the four quadrants of wellness:
Physical, Intellectual, Social, and Peace & Fulfillment.
Collaborates with service line leadership to plan, develop, and/or present continuing education programming that may include topics related to chronic disease management, wellness, nutrition, cognition, and fall prevention.
Tracks utilization of hospitalization, rehab, Skilled Nursing Facility, Assisted Living Facility and private duty on a monthly basis.
Collaborates with extended family/POA as necessary.
Represents Envisage and/or Encore at professional meetings, sales events, networking opportunities, community organization meetings, etc.
Maintains up-to-date files on resources available in the community for older adults.
Other tasks as assigned by the Executive Director, Envisage.
Supervisory
Responsibilities:
This job has no supervisory responsibilities.
Qualifications:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.
The requirements listed below are representative of the knowledge, skill, and/or ability required.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education and/or
Experience:
At least two years experience in case management.
Computer Skills:
To perform this job successfully, an individual should have knowledge of Contact Management systems; Internet software; Spreadsheet and Word Processing software and virtual meeting platforms.
Certificates, Licenses, Registrations:
Valid Driver's License Access to a registered and insured vehicle for frequent and regular travel between Members' homes and professional offices.
Other Skills and Abilities:
Experience in case management or related field with older adults, including demonstrated skills in assessment, planning, evaluating plans of care, organizing and maintaining detailed filing systems; familiarity with updated clinical assessment methods and community resources; an understanding of reimbursement criteria for Medicare and Medicaid; and excellent interpersonal skills with demonstrated ability to interact and communicate effectively with Members, families, staff, providers, professional community and others.
Physical Demands:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is regularly required to talk or hear.
The employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel; reach with hands and arms and taste or smell.
The employee must occasionally lift and/or move up to 10 pounds.
Specific vision abilities required by this job include close vision and distance vision.
Work Environment:
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Ability to travel using personal vehicle to Members' homes and professional offices in Allegheny, Armstrong, Beaver, Butler, Washington and Westmoreland counties.
The noise level in the work environment is usually moderate Recommended Skills Assisted Living Billing Case Management Clinical Works Coaching And Mentoring Communication Estimated Salary: $20 to $28 per hour based on qualifications.
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