- Acts as a liaison between members and home and community-based service providers to facilitate quality and cost-effective care and outcomes.
- Provides education and support to members and their families regarding community resources and services.
- Develop effective, collaborative relationships with key stakeholders including primary care providers, managed care plan providers, home and community-based service providers (HCBS), formal/informal caregivers and families.
- Maintains regular communication with members through phone calls and home visits to monitor their wellbeing and adjust careplans as needed.
- Records and documents interventions and member information completely and accurately, in accordance with payer and organization guidelines.
- Collaborates and communicates with internal team members, including Central Intake and Assessment Team members, to ensure continuity of care for assigned members.
- Identifies and resolves care plan variances, including barriers to primary and specialized medical care, to ensure effectiveness of member’s careplan.
- Assesses and addresses member engagement and behavior to support optimal health and functional status.
- Participates in after-hours on-call rotation requirements, as assigned.
- Maintains and monitors quality of services through collaboration with the Quality Assurance and Education Team and Care Management Director. Participating in Community Outreach as outlined in Quarterly Outreach plan.
- Bachelor’s degree in social work or related human services field is required with 2 years of work experience
- Experience in social work, home and community-based services, healthcare or geriatrics preferred.
Professional Field
Social Work
Other Behavioral, Mental, or Healthcare FieldPatient Focus
Diagnoses
Avoidant Personality Disorder
Age Groups
Preteens/Tweens (11-13)
Elderly (65+)
Therapeutic Approach
Methodologies
ECT
Practice Specifics
Settings
Research Facilities/Labs/Clinical Trials
Residential Treatment Facilities (RTC)
Home Health/In-home




