Care Plan Coordinator

Job Description

Job Description

JOB DESCRIPTION

Position: Care Plan Coordinator

Pay Range: $25.00-$30.00 PER HR

Reporting To: Clinical Nurse Manager

Work Type: Remote/Field

POSITION SUMMARY:

The Care Plan Coordinator is responsible for conducting in-person assessments of clients in skilled nursing facilities to evaluate their functional abilities, including activities of daily living (ADLs). This role involves close collaboration with facility staff, healthcare providers, and family members to ensure a comprehensive understanding of each client’s needs. The coordinator is accountable for accurately and promptly documenting assessments and recommendations, while maintaining strict compliance with applicable regulations and professional standards. This position requires strong clinical assessment skills, attention to detail, and the ability to work effectively within interdisciplinary teams to support optimal care planning and client outcomes.

QUALIFICATIONS:

1. Knowledge and experience in case management, discharge planning and/or skilled nursing care.
2. Possesses current CPR certification.
3. Knowledge of The State of California Assisted Living Waiver Care Coordination Agency preferred.
4. Experience in the field of education or training, quality assurance and management preferred.
5. Exercises excellent judgment and knowledge of current clinical practices, with demonstrated exemplary clinical, analytical, and documentation skills.
6. Good organizational skills.
7. Is self-directed with the ability to work with little supervision.
8. Proficient in the use of computers, and electronic information systems.
9. Ability to establish and maintain good communication and relationships with the office, field, and administrative personnel.
10. Familiarity with Title 22 preferred.
11. Must be a licensed driver with an automobile that is insured and is in good working order, in accordance with state and/or organizational requirements.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

The following is a representation of the major duties and responsibilities of this position. The agency will make reasonable accommodations to allow otherwise qualified applicants with disabilities to perform essential functions.

1. Conducts assessments determining each client’s level of care (i.e. tier).
   1. Speak to clients and find out if anything is needed, such as, DME’s, appointments, etc.
   2. Ask about medication compliance and other general assessment questions.
2. Develop Individualized Service Plans (ISP’s) and modify as needed.
3. Maintains proper charting, progress notes and case records for each enrolled client.
4. Updates client information on company tracking system of visit dates and when note is uploaded into EMR system.
5. Reports all signs of abuse or neglect to DHCS and the Ombudsman.
6. If there are Medi-Cal issues, communicate issues to client and facility staff and guide them how to resolve the issue if they are unaware.
7. Ensure you are uploading your notes by the end of the next business day from when you saw the client.
8. Maintain knowledge of confidentiality, HIPAA and healthcare laws and regulations.
9. Maintains proper timekeeping.
10. Follows policies and procedures as per Employee Handbook.
11. Maintains all credentials up to date.
12. Knowledge of mandated reporting.
13. Conducts timely recording and/or documentation of client contact.
14. Attends Department meetings (in person, by phone or by web).
15. Attends all State mandated in service trainings.
16. Significant amount of driving may be required throughout all areas Libertana services.
17. Performs other duties as assigned.

PHYSICAL REQUIREMENTS:

• Stand, sit, talk, hear, and use of hands and fingers to operate computer, telephone, and keyboard on a frequent basis up to 40% of the time.
• Reach, stoop, kneel and bend up to 20% of the time
• Moderate amount of walking up to 15% of the time.
• Moderate amount of driving up to 50% of the time.
• Close vision requirements due to computer work on a frequent basis
• Light to moderate lifting may be required up to 25lbs on a frequent basis.
• Pushing and pulling up to 25lbs.