Service Coordinator

Visiting Nurses Home Care • Albany, NY • 1d ago

Job description: Visiting Nurses Home Care is seeking an experienced Service Coordinator to assist the prospective participant to become a waiver participant and coordinates and monitors the provision of all services in the Service Plan for the Traumatic Brain Injury (TBI) Waiver and the Nursing Home Transition and Diversion (NHTD) Waiver. Services may include, but are not limited to, Medicaid State Plan services, non-Medicaid federal, state and locally funded services, as well as, educational, vocational, social and medical services. The goal is to increase the participants independence, productivity and integration into the community while maintaining the health and welfare of the individual. Responsibilities include: To comply with all state, federal and agency policies, procedures and regulations as appropriate to the Department of Health. To secure or attempt to continue to secure an advocate for each enrolled individual who requires or chooses to have one. All attempts must be thoroughly documented. In conjunction with the participant and his/her advocate: Obtains supporting information for planning and assistance in identifying valued outcomes of personal goals. Use basic listening skills for the purposes of obtaining a clear picture of valued outcomes and personal goals. Gathers information from service providers and others as needed. Arranges for and obtains clinical assessments, proof of disability (i.e. Social Security Award Letter, etc.), summaries, evaluations, etc. To assist the participant and his/her advocate in reviewing the gathered information and recommendations. To assist the participant and his/her advocate in establishing and prioritizing the persons goals, and to clearly define a chosen individualized service environment in which to reach those goals. To assist the participant in choosing the @types of activities, supports, and services that create the individualized service environment and are in line with their prioritized personal life plan. To formally review, update and submit timely Service Plans (Initial Service Plan, Revised Service Plan and addendum) to the Regional Resource Development Specialist (RRDS) for review; to review and update the individualized service plan at least semi-annually or as needed at the request of the participant and advocate and/or at the request of the DOH. To ensure that there is adequate coordination, appropriate communication and maximum cooperation between all sources of supports and services by maintaining ongoing contact with the participant, his/her advocate and service providers, as well as, intervening as appropriate with identified problems. To adapt the Service Plan to the changing needs and priorities of the participant as growth, temporary setbacks, and accomplishments occur. To maintain a minimum of one (1) face-to-face contact with each participant in each calendar month of the NHTD / TBI waiver enrollment, more often as needed. To ensure proper and complete documentation of each visit is recorded in a timely manner (within 24 hours of visit. To conduct in-home visits with each participant no less than once per quarter. To document service coordination activities in the Service Plan (i.e., SC Detailed Plan, SC ISR, SC section of ISP, RSP and addendum). Flexibility of schedule to ensure individual care and services are being met. To organize and facilitate team meeting. To assure that the PRI/Screen is completed a minimum of once every twelve months and/or when the participant experiences a significant change in his/her ability to function independently in the community. To continually ensure all waiver service providers and the participant receive a current copy of the most recently approved service plan and/or addendum. To maintain knowledge of all approved waiver service providers in their region for each participant. * To maintain records of waiver transport

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