Field Based HSS Clinical Coordinator RN - Southwest Kansas - Multiple Counties

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The Long-Term Services and Supports (LTSS) Care Coordinator RN is responsible for establishing a set of person-centered goal-oriented, culturally relevant, and logical steps to ensure that a person receiving LTSS receives services in a supportive, effective, efficient, timely and cost-effective manner. Care coordination includes case management, disease management, discharge planning, transition planning, and addressing social determinants of health and integration into community. This position is a Field-Based position with a Home Based office. Expected travelling 2-3 days per week within 30-60 mile radius. The counties covered by this position are Barton, Stafford, Pawnee, Edwards, Kiowa, Komache, Hodgeman, Ford, Clark, Gray, Meade, Seward, Haskell, Finney, Lane, Scott, Wichita, Greeley, Hamilton, Kearny, Grant, Stanton, Morton, Stevens. If you reside locally to or within 30 miles of one of these counties, KS or surrounding area, you’ll enjoy the flexibility to work remotely* as you take on some tough challenges.

Assess, plan, and implement care strategies that are individualized by the individual and directed toward the most appropriate, least restrictive level of care Identify and initiate referrals for social service programs, including financial, psychosocial, community and state supportive services Manage the person-centered service/support plan throughout the continuum of care Communicate with all stakeholders the required health – related information to ensure quality coordinated care and services are provided expeditiously to all persons Advocate for persons and families as needed to ensure the persons needs and choices are fully represented and supported by the health care team Conduct home visits in coordination with person and care team, which may include a community service coordinator Conduct in-person visits which may include nursing homes, assisted living, hospital or home Serve as a resource for community care coordinator, if applicable