The Social Worker participates in the care planning process in collaboration with the Care Manager, to include the following actions: assessment, goal setting, establishing interventions related to goals, identifying barriers and strategies to address, monitoring success of the interventions, evaluating the success of the overall care plan and reporting outcomes. Care Management activities are conducted through a combination of telephonic and face to face interactions which include visits to member homes, in the community, facilities and/or provider locations. Care management activities will focus on quality of care, compliance, outcomes and decreasing costs. Responsible for developing and carrying out strategies to coordinate and integrate post-acute and long-term care services to members to prevent exacerbations and/or placement of the members in custodial care. Performs initial and periodic assessments of the members enrolled in the Long-Term Care Program and/or care programs. Applies social work concepts, principles, and strategies in addressing the social determinants of health needs in members individualized care plan. Conducts regular discussion and updates with providers, primary care physicians, Medical Directors, pharmacists, and care management staff regarding the status of members and progress towards goals. Serves as a member advocate to ensure the member receives all the necessary care allowed under the member’s benefit plan and as available through Medicaid benefits and/or other community resources. Develops relationships with hospital social workers and community resources and utilizes available data to assure appropriate care management of catastrophic, acute, and chronically ill members with the goal of appropriate utilization, decreased length of stay, and preventable emergency room utilization. Assists in the identification and reporting of potential quality improvement issues. Directs social work interventions including performing psychosocial assessment of the populations, telephone follow up and in-home or facility assessments as indicated, documentation of problems, assessments, and/or interventions, and promoting ease of access to a continuum of care through appropriate information and referral. Controls comprehensive management of members with acute or chronic conditions, including case management activities that focus on quality of care, compliance, outcomes and decreasing costs for individuals and communities. Implements initial and periodic assessments of the members enrolled in the Long-Term Care Program and/or case or disease management programs under limited supervision to determine course of treatment. Applies in-depth knowledge of case management concepts, principles, and strategies in the development of an individualized case plan for enrolled members in case or disease management that are at risk of poor outcomes. Communicates updates and facilitates discussion with providers, primary care physicians, Medical Directors, pharmacists, and care management staff regarding the status of patients internally and externally. Identifies opportunities to ensure the member receives all the necessary care allowed under the member’s benefit plan in home or community setting. Provides information, resources, and education on social issues, mental health, and available services to raise awareness and empower individuals and communities. Develops complex, innovative programs designed to reduce admissions for acute and chronic members, increase community integration, and improve health outcomes for enrolled patients and outside individuals. Coaches more junior colleagues in techniques, processes, and responsibilities of social work to improve capacity. Collaborates with community members, organizations, and policymakers to create opportunities for clients, address community issues, or raise awareness for specific issues. Candidate must reside in Miami Dade County, FL. Must possess reliable transportation and be willing and able to travel up to 75% of the time (Mileage is reimbursed per company expense reimbursement). Must possess active and unrestricted Licensed Master Social Worker (LMSW)/ Licensed Clinical Social Worker (LCSW) licensure in the state of Florida. 2+ years experience in medical social work or case management. Bilingual (English + Spanish) preferred. Ability to multitask and manage complex cases. Experience in member crisis management. Proficient in Microsoft Office applications. Master's Degree in Social Work required. Active and unrestricted LMSW/LCSW licensure in Florida required. 40 hours per week, full time.