• LTSS Support Coordinator

    Job Locations US-MI-Southfield
    Req No.
    Regular Full-Time
  • Overview

    The Long Term Supports and Services Supports Coordinator works within a team environment partnering with the Care Coordinator (RN) to advocate and coordinate the continuum of care for our patients.  This role requires a high level of interaction with our patients to:

    • Perform effective outreach to complete necessary health and social assessments
    • Engage them in the development of an integrated, patient-centered care plan that takes into account needs across the continuum of care (health, social, psycho-social)
    • Support the patient in achieving their own goals as stated in the care plan as well as monitor adherence to treatment plans or other disease/chronic condition management programs
    • Work with a multi-disciplinary care team to develop interventions and changes to the care plan in response to patient’s needs and promotes positive health outcomes.


    • Perform comprehensive, team-based, and person-centered patient engagement
    • Document patient care plan tasks, goals, and interventions using appropriate mediums (e.g. EMR, historical claims data, outreach logs, etc.) in care coordination record system
    • Identifies caregiver training needs and tracks impact of needs and or training
    • Conduct discharge planning/coordination to ensure all post-discharge LTSS services required are in place Identify the appropriate utilization of resources across the continuum of care
    • Maintain patient/caregiver care plan compliance
    • Participate in quality improvement and evaluation processes
    • Perform and document reassessments, revisions to care plans, and coordinate interdisciplinary care team meetings in accordance with the (health plan) model of care requirements
    • Conduct face to face visits in member’s homes at a minimum of every 90 days, or as scheduled per member needs.
    • Complete all mandatory regulatory and other trainings required (including but not limited to: compliance training, first tier downstream and related (FWA) entity training, model of care training, etc.
    • Completes multiple comprehensive assessments to determine qualification for additional supports and services.
    • Collaborates with multiple team members (LTSS Coordinator, Care Coordinator, Patient Care Coordinator, and Management)
    • Assists with identification of high risk members that require a high intensity of care coordination and frequent contact
    • Coordinates community resources depending upon member needs
    • Provides assistance to identify the appropriate LTSS resources across the continuum of care
    • Other duties as assigned


    • LLMSW, LMSW, LBSW license in the State of Michigan
    • Bachelor’s degree or higher from a CSWE-accredited social work program
    • Minimum of three (3) years clinical experience, HMO /Managed Care setting preferred
    • Care Coordination/ Case Management training Knowledge community resources. Knowledge of clinical standards of care. Knowledge of Medicaid/Medicare contracts and benefit systems is preferred.
    • Local travel required for home visits, meetings with families, and other regularly meetings are required.
    • Willingness to adhere to spending required time in the office at the discretion of Management
    • Professional, flexible, and patient centered “team player” mentality


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