OverviewM Health Fairview has an immediate opening for a Social Worker Care Coordinator to support the Fairview Partners (FVP) team.This position will serve Fairview Partners members in the south Twin Cities metro and surrounding suburbs.This is a 1.0 FTE (80 hours per two week pay period) opening.This position will serve Fairview Partners members in the Twin Cities metro area - specifically Minneapolis and surrounding southwest suburbs.Responsibilities Job DescriptionFairview 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).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.QualificationsRequiredEducationBachelor’s degree in Social WorkExperienceTwo years of experience in medical social work, case management/care coordinationCritical thinking and ability to work with patients with complex health and psychosocial issues a mustLicense/Certification/RegistrationCurrent Minnesota Social Work license in good standingPreferredExperienceThree 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 industryLicense/Certification/RegistrationCurrent Minnesota Social Work license in good standingCertification in case managementAdditional 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.Other Skills We Desire:Knowledge of third party payers, billing procedures and insurance.Ability to work independently and exercise independent judgment.Excellent customer service, public relations and communication skillsAbility to prioritize and work with a fluctuation in workload while working independentlyAbility to adapt to change and engage in ongoing process improvementFlexibility to work at other sites is encouragedWe are an equal opportunity employer and value diversity at our company. We do not discriminate on the basis of race, religion, color, national origin, sex, gender, gender expression, sexual orientation, age, marital status, veteran status, or disability status. We will ensure that individuals with disabilities are provided reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. Please contact us to request accommodation.EEO StatementEEO/AA Employer/Vet/Disabled: All qualified applicants will receive consideration without regard to any lawfully protected status
