About this role
Duties and Responsibilities:
- Conduct comprehensive assessments of medical, behavioral health, and psychosocial needs.
- Identify risks for adverse health outcomes such as hospitalization, emergency visits, or functional decline.
- Develop individualized, person-centered Plans of Care based on client goals, strengths, and barriers.
- Implement and monitor care plans in collaboration with clients and interdisciplinary care teams.
- Review and update care plans regularly based on progress and changing needs.
- Provide health education and self-management support.
- Promote self-advocacy, independence, and wellness.
- Support clients in navigating insurance benefits and eligibility requirements.
- Advocate for timely access to care and removal of service barriers.
- Coordinate care following hospitalizations, emergency visits, or other critical events.
- Facilitate communication among primary care providers, specialists, behavioral health providers, and community supports.
- Maintain accurate, timely, and audit-ready documentation.
- Conduct home visits and community visits as required.
- Collaborate with families, caregivers, and service providers.
Qualifications:
- Bachelor’s degree in Social Work, Psychology, Human Services, Nursing, or related field.
- Minimum 2–3 years of experience working with adults in behavioral health, care coordination, case management, or community health.
- Strong organizational, communication, and problem-solving skills.
- Ability to work independently and within multidisciplinary teams.
- Experience in Medicaid care management programs.
- Knowledge of serious mental illness, substance use disorders, or chronic medical conditions.
- Bilingual in Spanish preferred.