Care Transition Manager Jobs in Decatur, GA (NOW HIRING)

CARE COORDINATOR, BSW – Cobb & Fulton

Visiting Nurse Health System (Visiting Nurse) is hiring for a dynamic with a high EQ Care Coordinator, BSW, for our Members in Cobb & Fulton Counties. We seek a Social Worker, BSW, who provides case management activities necessary to meet the needs of clients assigned to the consolidated care team. This position is responsible for the development of individualized care management plans; implementation of the care plan through brokering and coordinating services; and the monitoring and evaluation of all clinical outcomes to ensure that services are provided in a professional, comprehensive, and cost-effective manner. 

Who is Visiting Nurse Health System...
 Serving the Atlanta Area for over 78 years, Visiting Nurse is a leading provider of home healthcare, long-term care at home, hospice, and palliative care services, helping patients and their loved ones receive care at home following an illness, surgery, or hospital stay.

Our vision is to be the first choice for patients, families, payers, and other healthcare providers when they need home healthcare services. To achieve patient and employee satisfaction scores and clinical outcomes within the top 10 percent of all home healthcare providers in the U.S. To continue to invest in our strong community partnerships, coordinated care solutions, top-performing workforce, and innovative technologies to improve affordability throughout the healthcare continuum. To be a financially strong organization where healthcare professionals prefer to work.  For more information about Visiting Nurse, please visit vnhs.org.

In this position you will perform...

Coordination of Services: 

• Arranges both CCSP and non-CCSP community-based services in collaboration with the RN care coordinator, the client and family members.
• Coordinates Medicaid application team to assure that the CCSP is accessible to functionally impaired Medicaid eligible persons.
• Arranges emergency services as applicable.
• Coordinates with the lead agency or DHR as needed to assure that all components of CCSP are responsive to the needs of the client.
• Serves as the transition point and link between the assessment process and the effective delivery of direct services.

Assessment and Care Plan: 

• Develops appropriate care plans in consultation with the client, client’s family, and service providers.
• Implements the care plan and brokers the CCSP services.
• Complies with standards of promptness set forth by DHR policy regarding specific activities: Completes assessments within 5 days of referral. Follows up on direct services ordered within 10 days. Reviews care plan within the first 60 days of LOC date.
• Reviews care plans every 4 months at a minimum or more often as needed. Provides updated data monthly at a minimum for the purpose of reporting requirements. Completes a reassessment annually or refers to team RN for reassessment to avoid lapse of MD orders.

Documentation: 

• Documents all care management activity and service-related information.
• Ensures that documentation is consistent with the format required by depart cognitive standards (i.e., progress notes reflect care plans.)
• Maintains confidential case records on all CCSP clients.
• Demonstrates the ability to follow through in a thorough and timely manner on tasks assigned by management team and requests made by patients/families, referral sources, and community.
• Documents appropriate follow up on client needs whether related to CCSP services or other community resource needs.

Financial: 

• Limits amount and frequency of service to assure that costs do not exceed the limitations established by the Division of Aging Services and the Department of Community Health.
• Authorizes payment for service providers within the DHR standards of promptness following the service date.

Regulatory: 

• Requests redetermination of the client’s level of care prior to its expirations.
• Demonstrates knowledge and understanding of CCSP manual, Medicare and Medicaid regulations, physicians’ orders and the standards of care.
• Demonstrates knowledge of and adheres to the policies and procedures of Visiting Nurse Health System.

General Duties: 

• Maintains current knowledge of community resources to ensure that the care plan is realistic and to coordinate and/or arrange services to clients.
• Monitors service delivery to individual clients. Follows-up on each direct service to determine if it is being provided as appropriate and is effectively meeting the clients needs.
• Maintains current knowledge about the service standards for each CCSP service.
• Actively participates in interdisciplinary conferences to coordinate care, problem-solve, and exchange views and information. Documents case conference activities and follow up.
• Complies with standards of promptness set forth by DCH and VNHS policy regarding specific activities: 

Do you have a....

• Bachelor’s degree in Social Work, Sociology, Psychology, or a related field
• Two years of experience in case management in a health care field
• Two years of experience with Medicare, Medicaid and other Funding Source
• Reliable transportation including a valid driver's license and proof of vehicle insurance

Benefits:

• Medical, Dental, and Vision insurance
• Employee Assistance Program
• Employee Discount
• Flexible Schedule
• Flexible Spending Account (FSA)
• Health Savings Account (HSA)
• Life insurance
• PTO and 9 Holidays
• 403b w/company match 

Schedule:

• Full-time
• Monday- Friday

Compensation:

• This position pay range is $40,000 - 60,000

Visiting Nurse is an equal opportunity employer and does not discriminate against qualified applicants based on based on race, color, sex, gender, gender identity, gender expression, religious creed, sexual orientation, pregnancy, national origin, ancestry, age, military and veteran status, marital status, physical or mental disability, protected medical condition, genetic information, reproductive health decision-making, lawful off-duty use of marijuana, any other characteristic protected by law, or any combination of two or more of the characteristics listed here. If you need an accommodation to complete an online application, please contact Visiting Nurse at 404-215-6100.