POSITION: Geriatric Support Services Coordinator (GSSC)
DEPARTMENT: Special Programs
DESIGNATION: Non-Exempt / Union
SUPERVISOR: Sr. LTSS Manager
POSITION SUMMARY: The Geriatric Support Services Coordinator (GSSC) is a care manager assigned to work with SCO enrollees as well as serving as a member of the Primary Care Team (PCT). In partnership with the SCO Program Coordinator, the GSSC is responsible for coordinating and providing community social services to SCO enrollees as directed by a contract between CBES and SCO Plan, and in accordance with the SCO’s policies, procedures, and practices.
ESSENTIAL FUNCTIONS AND RESPONSIBILITIES:
- As a member of the Primary Care Team (PCT), participate in initial, ongoing, Post-Hospital Assessments of the health and functional status of enrollees via face-to-face, virtually, and /or telephonically. GSSC is required to participate in varies types of assessments as outlined in the contract between CBES and respective SCO Plans.
- Work in collaboration with the other Primary Care Team members to develop community-based care plans and related service packages necessary to improve or maintain an enrollee’s health and functioning.
- Arrange, coordinate, and authorize the provision of appropriate long-term care and social support services for enrollees (with the agreement of the PCT and following requirements set forth by the SCO). These may include but not be limited to ADL and IADL assist; housing; home-delivered meals; SNAP assistance; transportation, Mass Health Recertification, and referrals to other community organizations.
- Monitor the appropriate provision and functional outcomes of community long term care services that have been authorized by the PCT.
- Track enrollee transfers and adjust the service plan as deemed appropriate by the PCT and per requirements set forth by the SCO.
- Provide care management services in-person or via the telephone and email as requested by SCO RN.
- Prepare documentation and enter assessments in the agency database (SAMS and SCO CERs).
- Perform all services following state and federal law and written SCO management protocols, including timely entry of all information required recording in Centralized Enrollee Records (CER).
- Maintain care management documentation as specified in SCO care management protocols and directed by the CBES contact with the SCO plan.
- Report suspected Fraud, Waste and Abuse (FW&A) as required by CBES FW&A policy.
- Protect Consumers’ Personal Health Information (PHI) and report any suspected security breaches.
- Respond promptly to enrollee service requests.
- Attend and participate in PCT, agency and departmental meetings, team meetings, and CBES training as required.
- Complete all training as required by the SCO Plan.
- Perform other duties as assigned.
- Must have an ability to assess clients and their respective needs, in additional to having knowledge of the community-based service network.
- Excellent interpersonal and problem-solving skills required.
- Previous experience and a comfort level working with a diverse population of staff and a multi-disciplinary team.
- Access to a car is required.
- Knowledge of other languages preferred.
EDUCATION, SKILLS AND EXPERIENCE:
- Bachelor’s Degree and two years of professional experience in Case Management, Service Coordination, Outreach and/or advocacy with persons over the age of 65 preferred.
PHYSICAL REQUIREMENT OF THE JOB:
- Ability to lift and carry objects frequently weighing between 10-15 pounds.
- Ability to climb stairs.
- Ability to travel to the community to perform visits at consumers’ home.
- Work requires regularly standing, stooping and bending.