LOCATION: Health Plan Service - 4896

SHIFT: 8:30 AM - 4:30 PM

SEIU 73

Position Summary

The Long Term Care (LTC) Social Worker Care Coordinator (SWCC) supports the provision of care coordination in a manner that recognizes the Enrollee, medical home team, and (LTC) or supportive living facility (SLF) staff as essential partners in the Enrollee's care. The care coordination services are offered at the LTC/SLF facility. The LTC SWCC completes the assessment of healthcare needs and/or the social determinants of health that affect the provision of care. In collaboration with the Enrollee, the LTC SWCC uses assessment results to develop and implements a care plan to support care goals. Works with multiple disciplines to achieve the desired outcomes for the Enrollee.

Typical Duties

• Completes required assessments including health risk screenings, health risk assessments, conducting face to face visits with members in the LTC facilities, completing care plans based on needs, goals and risks identified in the health risk assessment. Collaborating with LTC facilities and providers to ensure that member has necessary durable medical equipment (DME), working to ensure that members are in contracted LTC facilities. The LTC SWCC in collaboration with LTC facility SW assesses the member's readiness to transition safely into the community in collaboration with other entities i.e. Colbert/Williams Decree.
• Provides care coordination services for County Care members on-site in long-term care facilities, including nursing homes, skilled nursing facilities, and supportive living facilities.
• Conducts required assessments and contacts to meet contractual requirements.
• Conducts face-to-face visits, in a timely manner, to assess member's care in the nursing facilities and SLFs
• Collaborates with members, families, and LTC facility to create care/service plan that reflects member goals and needs.
• Collaborates with members, licensed agencies, and LTC staff to assist with safe transition from the LTC facility into the community under the Colbert or Williams Consent Decree.
• Conducts quarterly face-to-face visits for one calendar year with Colbert/Williams Consent Decree members to review care plans, service plans, and assess home environment to ensure safe transition into communities and prevent re-entry into nursing facilities.
• Reports regulatory concerns identified in nursing homes, including abuse, neglect and exploitation to regulatory agencies, i.e. Illinois Department of Public Health, Adult Protective Services etc. Also, completes appropriate Critical Incident to report to managed care organization (MCO).
• Attends interdisciplinary care plan meetings in the nursing homes to address concerns identified by member and/or Care Coordinator, i.e. multiple hospitalizations, chronic health conditions, frequent falls, sentinel events, etc.
• Conducts record reviews to ensure that member is receiving all services prescribed by the physician as outlined in physician orders and/or care plan
• Addresses health concerns identified by member, family and/or care coordinator that LTC facility should escalate to physician.
• Performs other duties as assigned.

Minimum Requirements

• Licensed as a Social Worker in the State of the Illinois is required
• Two (2) years care coordination or work experience in a collaborative multi-disciplinary model is required
• Two (2) years of healthcare work experience is required
• One (1) year of experience in long-term care environment, i.e. nursing home or rehabilitation facility is required
• Valid Driver's license and mandatory vehicle insurance or other means of transportation is required

Preferred Qualifications

• Bilingual English/Spanish is preferred
  

Knowledge, Skills, Abilities and Other Characteristics

• Ability to work in fast paced and changing environment
• Excellent organizational skills
• Ability to work independently
• Excellent verbal and written communication skills
• Excellent critical thinking skills
• Excellent computer skills including ability to navigate in disparate systems, knowledge, and use of common software (Microsoft suite, SharePoint, etc.)
• Good working knowledge of managed care and care coordination

Physical and Environmental Demands

This position is functioning within a healthcare environment. The incumbent is responsible for adherence to all hospital and department specific safety requirements. This includes but is not limited to the following policies and procedures: complying with Personal Protective Equipment requirements, hand washing and sanitizing practices, complying with department specific engineering and work practice controls and any other work area safety precautions as specified by hospital wide policy and departmental procedures.

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of the personnel so classified.

For purposes of the American with Disabilities Act, "Typical Duties" are essential job functions.

PLEASE READ

When applying for employment with the Cook County Health & Hospitals System, preference is given to honorably discharged Veterans who have served in the Armed Forces of the United States for not less than 6 months of continuous service

To take advantage of this preference a Veteran must:

• Meet the minimum qualifications for the position.
• Identify self as a Veteran on the employment application by answering yes to the question by answering yes to the question, "Are you a Military Veteran?"
• Attach a copy of their DD 214, DD 215 or NGB 22 (Notice of Separation at time of application filing. Please note: If you have multiple DD214s, 215s, or NGB 22S, Please submit the one with the latest date. Coast Guard must submit a certified copy of the military separation from either the Department of Transportation (Before 9/11) or the Department of Homeland Security (After 9/11). Discharge papers must list and Honorable Discharge Status. Discharge papers not listing an Honorable Discharge Status are not acceptable

• A copy of a valid State ID Card or Driver's License which identifies the holder of the ID as a Veteran, may also be attached to the application at time of filing.