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HCR Home Care NHTDW Service Coordinator in Rochester, New York

Job Description

Role and Responsibilities

This position provides primary assistance to the waiver applicant/participant in gaining access to needed waiver and Medicaid State Plan services, as well as other local, state, and federally funded services. The SC assists the applicants/participants in obtaining and then coordinating the services necessary to return to or remain in the community and ensures adequate coordination, effective communication, and maximum cooperation between all sources of support and services for the participant. Will provide SC for up to 15 waiver participants.


Essential Functions

Assists applicant/participant with development of their individual SP while acting as an advocate for the participant to help participant obtain needed benefits and services and may assist participant locate a place to live.

  • Ensures Team Meetings are held as required. Provides all waiver providers, participant, and others with written summary of Team meetings and documents accordingly.

  • Maintains a tracking system for level of care evaluations and that PPR PRI and SCREENs are completed as required.

  • Assures a signed Release of Information is obtained.

  • Conducts face to face meeting with participant to;

1) Review service plan (SP) to determine if services are meeting participants needs;

2) Discuss provisions of services to determine level of satisfaction and

3) Review the detailed plan to discuss progress toward meeting participant’s goals.

  • Conducts in home visits at least once every six months, or, during first six months of the ISP, once every 30 days.

  • Reviews all NODs to ensure participant understands rights

  • Assures participant is provided with information regarding abuse/neglect prevention and reporting incidents

  • Develop and Maintain Detailed Plan for Service Coordination

  • Documents all visits, contacts, meetings, etc.

  • Works with participants on safe discharge plan if leaving the NHTD waiver program(s)

  • Administers Quality of Life Survey for applicants who reside in nursing home for at least six months prior to transitioning to the community.

Reviews, updates, and submits all SP’s to the Regional Resource Development Specialist.

Maintains knowledge of all approved waiver service providers in assigned region.

Maintains documentation according to waiver standards and indexed according to HCR policy and procedures

Attends quarterly meetings and others as assigned by Clinical Manager

Meets biweekly with Clinical Manager for case conferencing

Remains up to date with waiver changes per RRDC


Education Requirements

One of the following;

  • MSW, Masters in Psychology, Licensed in NYS as a PT, OT, RN, SLP, OT, or Certified Special Ed Teacher or Certified Rehabilitation Counselor AND;

Qualifications and Requirements

One of the following;

  • Minimum of 1 year of experience providing SC and information, linkages and referrals regarding community based services for individuals with disabilities and/or seniors; OR

  • BA degree and two years experience providing service coordination for individual with disabilities and/or seniors and knowledge about community resources OR

  • HS Diploma with 3 years experience providing service coordination for individual with disabilities and/or seniors and knowledge about community resources OR

  • Successfully served as a Regional Resource Development Specialist for one (1) year.

  • This role will require critical thinking skills, strong organizational skills and excellent communication skills.

  • Must be able to operate independently.


EOE/AA Minority / Female / Disability / Veteran

EOE Minorities / Females / Protected Veterans / Disabled

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