Fairview 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).
This is a 1.0 FTE (40 hours per two week pay period), benefits-eligible opening.
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
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 members 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
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
Preventative Health Education: Provides education on preventative health measures, as appropriate, for members 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 members right to autonomy and self-determination and recognizes reportable risk
Advance Care Planning: Maintains knowledge of advance care planning principles; follows Fairviews system advance care planning policies and procedures to promote a culture of informed health care decision-making that honors a members 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.
Bachelors degree in social work
Two years of experience in medical social work, case management/care coordination; critical thinking and ability to work with patients with complex health and psychosocial issues a must
Current Minnesota Social Work license in good standing
Bachelors degree in social work or higher
Three 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 industry
Current Minnesota Social Work license in good standing, Certification in case management
Additional Requirements :
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
Together with the University of Minnesota and University of Minnesota Physicians we have created M Health Fairview. M Health Fairview is the newly expanded collaboration among the University of Minnesota, University of Minnesota Physicians, and Fairview Health Services. The healthcare system combines the best of academic and community medicine — expanding access to world-class, breakthrough care through our 10 hospitals and 60 clinics.
Fairview Health Services (fairview.org) is an award-winning, nonprofit health system providing exceptional care across the full spectrum of health care services. Fairview is one of the most comprehensive and geographically accessible systems in the state, with 10 hospitals—including an academic medical center and long-term care hospital—serving the greater Twin Cities metro area.
Its broad continuum also includes 60 primary care clinics, specialty clinics, senior living communities, retail and specialty pharmacies, pharmacy benefit management services, rehabilitation centers, counseling and home health care services, medical transportation, an integrated provider netwo...rk and health insurer PreferredOne. In partnership with the University of Minnesota, Fairview’s 32,000 employees and 2,400 affiliated providers embrace innovation to drive a healthier future through healing, discovery and education.