A MI Choice Support Services Coordinator (SSC), assists Northern Health Care Management Licensed Supports Coordination staff in working with participants who are re-enrolling in MI Choice, enrolling after a nursing facility or hospital discharge, or otherwise assisting the participant with obtaining assistance in the community. Essentially, the SSC will perform the work of a Community Health Worker (CHW) and be unlicensed but must be trained in the duties of the job.
ESSENTIAL POSITION FUNCTIONS (listing Position Specific functions first):
- Engage and work alongside unit members, performing the tasks of the unit.
- Assist members with all aspects of community support services (including housing and entitlements).
- Prepare and submit paperwork (including monthly progress notes, reports, etc.), in a consistent and timely manner.
- Establish and update goals and recording progress of members, with members.
- May be assigned to complete visits with the participant at home within 3 days of hospital or facility discharge to review the discharge paperwork and any other documentation, review any medications received or orders that need to be filled, remind the participant of the importance of filling the medications, and talk with the participant about the importance of following up with the physician. If needed, the SSC may make calls for medication to be filled, or to arrange for the follow-up appointment with the physician. The SSC also trains the participant about anything to be aware of and what to do if his/her condition worsens.
- Complete follow-up visits with participants in their own home as necessary. Must thoroughly document contacts with the participant, so the Supports Coordinator is aware of what occurred. If there are medication discrepancies, the SSC will follow up with the RN Supports Coordinator to get those issues addressed.
- Thoroughly document what was discussed and discovered during the contacts with the participant, so the Supports Coordinator is aware of what occurred. If there are medication discrepancies, the SSC will follow up with the RN Supports Coordinator to get those issues addressed.
- May visit the individual in the nursing facility or hospital to ensure the staff knows who to contact to coordinate the discharge home. The SSC ensures the nursing facility or hospital staff has the contact of the Supports Coordinator with whom the discharge should be coordinated.
- If the Supports Coordinator wishes and the participant agrees, the SSC will be in contact with the nursing facility if a participant goes from a hospital to a nursing facility for temporary rehab before returning to the Waiver. The SSC may assist with coordinating any supplies, services, etc., the participant requires at home after rehabilitation.
- May perform the duties of a supports broker. They may provide assistance throughout the planning and implementation of the service plan and individual budget, assist the participant in making informed decisions about what works best for the participant, assist the participant to explore the availability of community services and supports, assist with access to housing and employment, and assist with making the necessary arrangements to link the participant with those identified supports.
- Offer practical skills training to enable individuals to remain independent, including the provision of information on recruiting, hiring, and managing workers, effective communication skills, and problem solving.
- May coach participants in managing health conditions, assist with scheduling appointments, facilitate coordination between various providers, and assist the participants with completion of applications for programs for which they may be eligible.
- Work in close collaboration with the participant’s Supports Coordinator as the Supports Coordinator has ultimate responsibility for the participant’s case.
- Other duties that may be assigned.
MINIMUM EDUCATION & EXPERIENCE:
- A bachelor’s degree in a related human services discipline and, or a bachelor’s degree.
- A Community Health Worker certificate or willingness to complete the training within the first 30-60 days employment.