Job Summary
The purpose of this position is to complete needs-based eligibility determinations for patients who are applying for Medicaid-funded personal care services provided in their home or in adult care or supervised living homes. This position also assesses level of care (LOC) to allow targeted individuals to remain in or return to a home and community-based setting.
***This role requires a valid driver's license and travel to various locations, which may include extended periods of driving (up to approximately 8 hours in a day and can drive up to 120 miles a day)***
Responsibilities
- Conduct assessments to determine whether the beneficiary meets the conditions and criteria for PCS eligibility, using state-approved standardized assessment tool(s).
- Ensure PCS are provided on a "needs basis" in quantities appropriate to the Beneficiary's unmet need for services based on the severity of their medical condition, functional disability, physical, or cognitive impairment.
- Ensure the privacy and dignity of individuals receiving assessment for PCS is maintained at the highest standards.
- Ensure that new, expedited, annual, change of status, mediation/appeals, reconsideration review, and derivative assessments are conducted within established timeframes.
- Include an interview with family members and informal caregivers who are present at the time of the assessment.
- Provide the Beneficiary with guidance and assistance, as necessary, to select PCS providers.
- Conduct service plan reviews as needed.
- Submit the completed assessments using state-approved interface.
- Participate in the Beneficiary's mediation and appeal processes.
- Respond to state inquiries regarding assessments conducted.
- Attend and actively participate in staff meetings and conduct case consultations/peer reviews/internal auditing as assigned.
- Provide assessments for initial eligibility determinations for an applicant to participate in a 1915(c) HCBS program, and, when applicable, annual and change of status assessments for participants currently participating in a 1915(c) HCBS program, using state-approved standardized assessment tool(s).
- Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules.
The list of accountabilities is not intended to be all-inclusive and may be expanded to include other education- and experience-related duties that management may deem necessary from time to time.
Required Qualifications
- Registered Nurse (NC or Compact license)
- Minimum of two years of nursing experience.
- This position requires travel up to a 120 miles roundtrip.
Preferred Qualifications
- Experience with community-based individuals needing personal assistance with ADL and IADL tasks is highly preferred.
- Experience conducting PCS assessments highly preferred.
- 2+ years of home healthcare experience preferred.
- 2+ years of directly-related experience (preferably case management) in the health or medical field, directly related to homecare, long-term care, or personal care is preferred.
- Experience conducting HCBS waiver assessments highly preferred.
- Knowledge of North Carolina Medicaid Clinical Coverage Policy (Clinical Policy) 3L and PCS Program Provider Manual
- Knowledge of standards of practice related to Medicaid-funded Personal Care Services, home and community-based services (HCBS) programs, and EPSDT.
- Knowledge and understanding of public sector services and supports.
- Computer proficiency in Microsoft Excel, Word and Outlook.
- Ability to utilize computer equipment and web-based software to conduct work.
- Ability to interact with various office staff as needed to support necessary workflows.
- Ability to interact with healthcare professionals, patients, their families and other supports.
- Ability to communicate effectively to individuals and groups through spoken, written and electronic media.
- Ability to attend to detail, effectively prioritize and execute tasks in a timely manner.
- Ability to work independently without a high degree of supervision.
- Develops level of care recommendations based upon clinical evaluations.
- Participates in training of PCS stakeholders as needed.
- Ability to use person-centered thinking, planning, and have competency in awareness of the needs of persons with disabilities.
- Knowledge of North Carolina Medicaid Clinical Policy 3K-1 and 3K-2, and 42 CFR Part 441 Subpart G, 42 CFR § 440.180.
- Knowledge of eligibility criteria for LOC and Waiver Participation.
- Knowledge of standards of practice related to Medicaid waivers, home and community-based services (HCBS) programs, EPSDT, medical fragility, and level of care determinations.
- Participates in training of CAP stakeholders as needed.
Pay Range
USD $77,000.00 - USD $80,000.00 /Yr.