Provides comprehensive case management services to Meals On Wheels. Conducts initial assessments for all new Monroe County Office for the Aging (MCOFA) participants to identify needs and determine appropriate level of support. Develops and coordinates person-centered care plans for participants with complex needs, facilitating connections to community services and resources that enable them to age safely at home. Works collaboratively with MOW program staff to ensure seamless, integrated service delivery and provides expert consultation on participant needs as they evolve.
Responsibilities
Qualified individuals must be capable of performing the following essential duties and responsibilities, with or without reasonable accommodation:
Initial Assessment & Triage
- Conducts comprehensive initial assessments (COMPASS) for all new MOW participants home visits to evaluate health status, functional abilities, social support, environmental conditions, and service needs.
- Determines appropriate level of ongoing support based on assessment findings, identifying participants with complex needs who require active case management versus those appropriate for standard monitoring by diet technicians.
For participants with identified complex needs requiring ongoing case management:
- Develops and coordinates person-centered care plans in collaboration with participants and service providers.
- Provides assistance with accessing services and benefits, including coordinating in-home support services, arranging home safety assessments and modifications, facilitating healthcare and transportation connections, and assisting with benefit applications (e.g., SNAP, HEAP).
- Serves as a professional resource and consultant to participants, helping them navigate the service network.
- Conducts documented follow-up contacts at least every two months to monitor progress and adjust service plans as needed.
- Facilitates warm handoffs to community partners and specialized services when participant needs exceed program scope, ensuring seamless transitions and successful service connections.
Documentation & Compliance
- Maintains timely, accurate, and confidential documentation of all case management activities in the NYS Health Commerce System and NYSOFA Statewide Client Database.
- Completes required assessments, reassessments, care plans, and follow-up documentation in accordance with MCOFA and NYSOFA regulations.
- Ensures all participant information is treated confidentially and referrals are made with appropriate consent.
- Retains documentation for required retention periods and completes case file reviews and audits as needed.
Professional Development & Collaboration
- Maintains active New York State Office for the Aging (NYSOFA) Case Management Certificate and completes required continuing education (16 hours annually).
- Stays current on aging services regulations, community resources, and professional best practices through ongoing education and training.
- Participates actively in internal program meetings, external community partner meetings, and case reviews.
- Collaborates with MOW program staff, volunteers, and community partners to ensure coordinated service delivery.
- Other duties as assigned.
*Note: The above information on this job has been designed to indicate the general nature and level of work performed by employees within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of employees assigned to this job.
Qualifications
Education & Experience - Applicants must possess the following qualifications or an equivalent combination of education and experience:
- Education: Bachelor’s Degree in Human Services or related field with one year experience in the field of Aging. (BSW preferred). Equivalent combination of education and experience will be considered.
- Experience: 2 years in Human Services, preferably in the field of Aging.
Licensure, Certification, and/or Credential:
- Valid NYS Driver’s license with reliable transportation. Bilingual in Spanish preferred.
- NYSOFA Case Management Certificate preferred or willingness to acquire within first four months of hire. Recertified every five (5) years with 16 hours per year of required continuing education.
Knowledge, Skill, & Ability Requirements
- Ability to prioritize assignments, plan, and complete work projects with minimal direction.
- An ability to work efficiently and effectively and meet deadlines.
- An ability to work under pressure.
- Excellent verbal/written skills.
- Ability to maintain confidentiality.
- Ability to demonstrate behaviors and attitudes which support agency mission, philosophy, and policies.
- Willingness and ability to foster agency and program wide cooperation and teamwork through use of positive/constructive communication techniques
Technical & Systems/Equipment Proficiencies
- Microsoft Office Suite: Outlook, Word, Power Point and Excel
Other
- Valid Driver’s License
- Current Auto Insurance
- Travel throughout service area year around.
Physical Requirements: The position involves frequent sitting, standing, and walking. Tasks such as kneeling, squatting, reaching, twisting, balancing, climbing, bending, pushing and pulling are required infrequently.
Salary: $38,126 - $80,912
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