• Bachelor’s degree in Nursing or Social Work
• Licensed Registered Nurse (RN) or Licensed Social Worker (LSW) in Minnesota
• 2+ years of experience working with MSHO, MSC+, and SNBC Populations
• Experience with state-based assessments (DHS, LTCC or MnCHOICES)
• Proficiency with clinical documentation tools, Happian, and Microsoft Office tools.
• Motivational interviewing and cultural competency required.
• Valid driver’s license, reliable transportation, and ability to conduct in-home visits
• Mandated reporter

Essential Functions:

• Provides comprehensive assessment or screening of each member’s social, medical and environmental safety needs. Documents information in a timely manner on appropriate forms.
• Conducts required in person and telephonic visits on a timely basis.
• Performs review of medical records in the appropriate EMR.
• Develops Person Centered Care Plans based on assessment requirements, maximizing the level of self-determination and member choice of services, service providers, and living arrangements to meet identified needs. This includes disease management, advance directive planning, and vaccination updates.
• Incorporates interdisciplinary, holistic, and preventive care across all settings of care per CMS timeline.
• Provides culturally appropriate care.
• Communicates care needs and plan of care with members and/or member representatives, primary physicians, and interdisciplinary team members through written and/or verbal communication.
• Contacts appropriate personnel in hospital, nursing facility, foster care or assisted living settings to share and obtain necessary information that will facilitate discharge of the member to the appropriate level of care.
• Communicates with service providers and members while assisting with arrangement and authorization of services and issue denials of inappropriate services in a timely manner.
• Interdisciplinary collaboration with population health team when members have complex medical needs.

• Hybrid role with regular travel to member homes, nursing facilities, assisted living, and community settings.
• Frequent in-person contact with members in uncontrolled environments (e.g., homes, facilities).
• Personal, reliable vehicle required; must maintain valid driver’s license and insurance.
• Remote work involves prolonged sitting, screen use, virtual meetings, and documentation.
• Requires a professional, distraction-free home workspace, with reliable and secure internet access.
• Must adhere to organizational data security and privacy standards for handling sensitive PHI- HIPPA.
• Standard office equipment is used, including a computer, headset, printer, scanner, telephone, and web-based fax systems.
• Occasional lifting or movement of items (e.g., reports, files, small office equipment) up to 25 lbs.
• Must work independently, manage multiple complex tasks, and prioritize competing demands.
• Requires high productivity, attention to detail, and clinical decision-making with limited or evolving information.
• Must demonstrate emotional resilience and professionalism during sensitive or high-impact situations (e.g., unsafe housing, behavioral health issues).