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Position Summary

The DSCC Home Care nursing consultant provides care coordination services to families eligible for DSCC's Home Care program.

The Home Care program serves Medicaid non-waiver participants under 21 years and those eligible for the Persons who are Medically Fragile, Technology Dependent (MFTD) waiver program.

This position is responsible for engaging and building strong partnerships with the families enrolled in the program through monthly interactions, completion of comprehensive assessments, person-centered care plans, and engagement with multiple stakeholders.

It also offers consultation to other members of the multi-disciplinary team utilizing skills and knowledge acquired from academic training and professional experience as a Registered Nurse.

Duties & Responsibilities 

Under the direction of the regional manager, performs active care coordination services by completing comprehensive health assessments, identifying families' strengths, and developing a person-centered service and care plan.

Ensure that the participant and/or legally responsible adult understand the waiver services furnished to the participant, estimated frequency, and provider type.

Facilitates 30-day ( or as needed) monitoring of the person-centered care plan, assesses/determines status change, prioritizing unmet needs and location of resources.

Utilize a culturally - competent approach as guided by the university to support families' cultural values and traditions.

Utilize as necessary interpreter language line and accommodation resources based on the university's Americans with Disability Act (ADA) guidelines, such as American Sign Language (ASL).

Promotes interagency collaboration through entities such as HFS, DCFS, and other community or state agencies committed to the participant's care.

Educate, support, and connect non-waiver families with resources for a seamless age transition. Similarly, provide age-transition support to waiver families exiting the program due to health improvement.

Completes consistent and timely documentation (within 48 hours) to ensure compliance with waiver and non-waiver renewal requirements and timelines without direct manager support.

Conduct and document in-person visits at home or other appropriate settings like schools or hospitals every 6 months or as needed according to federal waiver requirements.

Identify/escalate and facilitate internal team meetings on participants with complex behavioral/social determinants or clinical factors impacting their well-being.

Identifies critical incidents and collaborates with all involved parts for resolution.

Active participation in post-records reviews and completion of recommended remediation within expected timeline.

Contribute to quality improvement initiatives, including but not limited to attendance at quality huddles and provision of recommendations as needed.

Arrange, lead, and contribute with areas of expertise to multi or interdisciplinary care team meetings with participants' providers, family members, nursing agencies, or school teams.

Apply effective communication skills to improve families' health literacy.

Manages clinically complex caseload participants resulting from neglect or abuse allegations, illness progression, or caregivers' hardship. 

May support other licensed and unlicensed care coordinators in verifying and interpreting clinical conditions, treatments, mental/behavioral health diagnoses or concerns, guiding priorities on the person-centered care plan, and recommending resources.

May mentor/coach care coordination team members and participants/caregivers on self-management of chronic diseases, medication adherence, and prevention.

Serves as a consultant for team members supporting families undergoing transitions of care.

May contribute as a subject matter expert on health education initiatives such as immunizations, weight management, the importance of physical activities, etc.

Assists families with private/public health insurance through effective benefits management practices for recipients.
Complies with the University, Division, and Regional Office policies, and procedures.
The list of responsibilities is not all-inclusive and could be extended to include other obligations, special projects, or tasks as indicated by contractual requirements, DSCC leadership, and management at any time.