Summary:
The AFC-GAFC provider must employ a care manager to provide an initial psychosocial and ongoing evaluation for the AFC-GAFC program, as well as maintain communication with the client’s medical team. In addition, this person is responsible for identifying and accessing additional resources to support and to assist clients and their families in his/her caseload, and for maintaining direct communication with the AFC GAFC Program Director and the Care Manager Supervisor.

Essential Duties and Responsibilities:

• Conducting initial psychosocial and ongoing evaluations of a member’s appropriateness for AFC
• Evaluating, supporting, and training AFC-GAFC caregivers
• Assisting with the development of the member’s interim and final AFC-GAFC plan of care with input from the member or responsible party, all members of the MDT, and other individuals designated by the member.
• Ensuring implementation of the AFC-GAFC plan of care
• Conducting on-site visits with each member at the qualified setting bimonthly (alternating with the bimonthly visit by the care manager) for Level I and Level II, and monthly or more often as the member’s condition warrants.
• Assisting with coordination of AFC-GAFC with any other health services or supportive services the member is receiving from Mass Health, a managed care organization, an accountable care organization or other agencies or organizations including, but not limited to, visiting nurse services, therapy services, Department of Developmental Services (DDS) services, Department of Mental Health (DMH) services, and Massachusetts Rehabilitation Commission (MRC) services
• Completing a care manager progress note corresponding with each on-site visit or encounter, or more often as the member’s condition warrants
• Reporting changes in the member’s condition to the member’s AFC registered nurse
• Monthly review of AFC-GAFC Caregiver Logs
• Assisting with making referrals to appropriate service providers if the member requires services other than those provided by the AFC-GAFC provider
• Conducting regular, periodic evaluations, at least annually, to ensure that each qualified setting where AFC is provided meets the requirements of 130 CMR 408.435
• Providing timely assistance and responding to urgent or emergency needs of the member
• Participating in discharge planning and implementation of discharge
• Reviewing and documenting the fire and safety procedures for the qualified setting

Qualifications:

• Must have strong interpersonal skills and be able to interact effectively both internally and externally with individuals from different social, cultural, racial and economic backgrounds
• Ability to transmit, receive and accurately interpret ideas, information, needs and general business data through the application of appropriate communication behaviors
• Strong communication skills both verbally and in writing
• Ability to effectively present information and respond to internal/external inquiries (e.g. staff, clients, etc.)
• Ability to work well under pressure in a fast-paced, time-sensitive environment
• Ability to work on a multi-disciplinary team, as well as independently
• Working knowledge of Microsoft Office products (Outlook, Excel, Word)
• Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists

Education & Experience:

• Bachelor’s degree in Human Services or related field from a college/university accredited by the U.S. Department of Education, a Social Worker license from the Massachusetts Board of Registration in Social Work, and two years’ recent experience working with elders or adults with disabilities OR:
• Bachelor’s degree and two years of clinical experience in the care of elders or people with disabilities.

Physical Demands:

• Ability to be physically mobile (stand, walk, reach, climb, bend) and also the ability to sit for prolonged periods throughout the day/work hours
• Manual dexterity sufficient to operate keyboard, copier, telephone, and the ability to write and/or type
• Must be able to occasionally lift and/or move up to 25 pounds
• Occasional driving to client appointments, off-site meetings, conferences, etc.

Other Requirements:

• Valid driver’s license
• Recent physical exam and TB screen within 12 months