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.