Community Based Waiver Service Coordinator (RN, LSW, ...

Job Summary:The Community Based Waiver Service Coordinator, Duals Integrated Care is responsible for managing and coordinating services for individuals who require long-term care support and are eligible for community-based waiver programs, ensuring that members receive the necessary services and supports to live independently in their communities while also coordinating care across various healthcare and social service systems.Essential Functions:Engage with member in a variety of community-based settings to establish an effective, care coordination relationship, while considering the cultural and linguistic needs of each member.Conduct comprehensive assessments to determine the needs of members eligible for community-based waiver services.Develop individualized service plans that outline the necessary supports and services, ensuring they align with the individual's preferences and goals.Serve as the primary point of contact for members and their families, coordinating care across multiple providers and services, including healthcare, social services, and community resources.Facilitate access to necessary services such as home health care, personal care assistance, transportation, and other community-based supports.Regularly monitor the implementation of service plans to ensure that services are being delivered effectively and that individual needs are being met.Conduct follow-up assessments to evaluate the effectiveness of services and make adjustments to person-centered care plans as needed.Advocate for the rights and needs of members receiving waiver services, ensuring they have access to the full range of benefits and supports available to them.Empower members and their families/caregivers to make informed decisions about their care and support options.Build and maintain relationships with healthcare providers, community organizations, and other stakeholders to facilitate integrated care.Lead and collaborate with interdisciplinary care team (ICT) to discuss individual cases, coordinate care strategies, and create holistic care plans that address medical and non-medical needs.Provide education and resources to members and their families/caregivers about available services, benefits, and community resources.Offer guidance on navigating the healthcare system and accessing necessary supports.Maintain accurate and up-to-date records of member interactions, care/service plans, and progress notes.Assist in preparation of reports and documentation required for compliance with state and federal regulatory requirements.Respond to crises or emergencies involving members receiving waiver services, coordinating immediate interventions and support as needed.Evaluate member satisfaction through open communication and monitoring of concerns or issues.Regular travel to conduct member, provider and community-based visits as needed and per the regulatory requirements of the program.Report abuse, neglect, or exploitation of older adults as a mandated reporter as required by State law.Regularly verify and collaborate with Job and Family Service to establish and/or maintain Medicaid eligibility.On-call responsibilities as assigned.Perform any other job duties as requested.Education and Experience:Nursing degree from an accredited nursing program or Bachelor's degree in health care field or equivalent years of relevant work experience is required.Minimum of 1 year paid clinical experience in home and community-based services is required.Medicaid and/or Medicare managed care experience is preferredCompetencies, Knowledge and Skills:Intermediate proficiency level with Microsoft Office, including Outlook, Word, and ExcelPrior experience in care coordination, case management, or working with dual-eligible populations is highly beneficial.Understanding of Medicare and Medicaid programs, as well c

Created: 2025-10-14