Geriatric Care Manager

Job Description

CBES is Hiring For the Following (Senior Care Options) SCO plans:

BMC - (WellSense)

Tufts

Senior Whole Health (SWH)

United

Commonwealth Care Alliance (CCA)

POSITION SUMMARY:

The Geriatric Care Manager is assigned to work with consumers enrolled in the Senior Care Option (SCO) Program and/or State Home Care Program. He/she will be chiefly responsible for assessing consumers' needs, coordinating visits, and providing community social services to SCO and/or State Home Care Program enrollees as directed by a contract between CBES, Executive Office of Elder Affairs (EOEA), and SCO Plans.

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES:

Participate in initial, ongoing, and post-hospital assessments (face-to-face, virtual, hybrid, and telephonic) of enrollees' health and functional status.

Attend Interdisciplinary and Primary Care Teams (ICT and PCT) meetings with members of the clinical and management staff to keep abreast of the consumer's care plan.

Work in collaboration with the ICT and PCT team members to develop and implement community-based care plans and related service packages necessary to improve or maintain a consumer's well-being, health, and functioning.

Advocate for elders when necessary and encourage elders' participation in service plan implementation as outlined by CBES.

Refer elders to other programs when appropriate, which may include Medicaid Waiver, Respite, Managed Care, Supportive Housing, or other relevant resources. These may include but not be limited to ADL and IADL assistance; home-delivered meals; SNAP assistance; transportation, Mass Health Recertification; and referrals to other community organizations.

Assist elders with housing issues, public assistance, insurance, and financial benefits, long-term care admissions, and legal matters, including identifying needs, locating resources, and completing all applications and paperwork as necessary.

Monitor the appropriate provision and functional outcomes of community long-term care services that the ICT/PCT has authorized.

Track consumers' transfers between programs, community, and in-patient settings and adjust the service plan as deemed appropriate by the ICT/PCT and per requirements set forth by the EOEA and SCO plans.

Maintain up-to-date client records, including progress notes and all other required forms.

Complete and submit to the supervisor on a timely basis all home care forms, referral forms, and data entry documents as required by EOEA regulation, SCO Contracts, and Agency policy.

Perform all services following state and federal law and written EOEA, SCO, and Agency management protocols, including timely entry of all required information in the State SAMS database and SCO Centralized Enrollee Records (CER).

Complete, review, and submit all statistical information and other administrative paperwork required by Care Manager Supervisor and current Agency policy.

Identify elders in at-risk situations, including abuse, neglect, and financial exploitation. Report to and collaborate with appropriate crisis intervention agencies, including Protective Services and Elders at Risk programs, to alleviate abuse, neglect, and other crises.

Work in collaboration with other CBES Departments to ensure timeliness and quality of care delivery as set by the EOEA regulation, Central of Medicare and Medicaid (CMS) Quality Measures, and Agency policy.

Participate in peer case review and non-routine wellness check home visits. Provide feedback on vendor service provision for annual audits.

Update professional skills and knowledge of community resources and gerontological issues. Keep informed of all current Agency and EOEA regulations, policies, and procedures.

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.

Attend and participate in ICT/PCT, agency and departmental meetings, team meetings, and CBES training as required.

Bilingual Geriatric Care Manager must provide translation between CBES staff and non-English-speaking clients as needed., and assist the translation of written material, e.g., brochures, letters, forms, etc., when required.

Perform other duties as assigned.

QUALIFICATIONS:

Must have an ability to assess clients and their needs and knowledge of the community-based service network.

Excellent interpersonal and problem-solving skills are required.

Must have and ability to work with a diverse population and within a multi-disciplinary team.

Access to a car is required.

Knowledge of other languages preferred: Spanish, Cantonese, Mandarin

EDUCATION, SKILLS, AND EXPERIENCE:

Bachelor's Degree in Human Services, Social Work, Nursing, or equivalent experience and a minimum of three years’ experience in the human services field, preferably working with elders. Must have a basic knowledge of gerontological issues.

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' homes.

Work requires regular standing, stooping, and bending.

Ability to carry a laptop and documents required to complete a home visit.