Overview

Provides care management for clients in collaboration with the Wellness case management team consistent with WeCARE and the VNS Home Care policy and requirements of the Wellness Care Management program. Facilitates the coordination of services between the varying providers for clients with complex psychiatric and/or co-morbid medical conditions who are deemed to be temporarily unable to work. Ensures efficient and successful access and linkage to the full array of necessary physical and behavioral health services. Coordinates effective communication between all providers to the ultimate benefit of the patient. Works under close supervision.

Compensation Range:$23.17 - $28.96 Hourly

What We Provide

What You Will Do

• Reviews and utilizes completed medical and mental health assessments from the ResCARE clinical team when initiating the wellness plan for clients on the temporarily unable to work track. . Confirms acuity level of identified client and tailors services plan accordingly.
• Develops and monitors wellness plan on behalf of clients with untreated or unstable medical and/or mental health conditions adversely affecting the level of employability. Coordinates and integrates a written, coordinated wellness plan in cooperation with the client the client’s family, and/or other providers serving the client.
• Performs and maintains effective care management for a caseload of clients, as assigned, from wellness initiation to wellness completion. Meets with assigned clients to monitor progress and compliance with the wellness plan. Tracks/ monitors client progress and produces/maintains detailed, accurate and timely case notes. Reviews cases for completeness of documentation.
• Develops inventory of resources that will meet the clients’ needs as identified in the assessment process. Becomes familiar with service providers in the community where the clients resides in order to mitigate barriers to wellness plan compliance such as transportation, childcare etc.
• Provides linkage, coordination with, referral to and follow-up with appropriate ongoing service providers. Participates in meetings with service providers to coordinate service and follow up to ensure client’s compliance with and timely completion of the wellness plans and required documentation.
• Works collaboratively with team members to provide outreach (Via Phone calls, Emails, Texts and Field visits) to clients who have failed to comply with the process of the initiated wellness plan and wellness care management services.
• Provides information and assistance through advocacy and education to client/family on availability and eligibility of entitlements and community services. Assists with arranging escorts and transportation for clients to appropriate facilities/agencies, as necessary.
• Participates in initial and ongoing trainings as necessary to maintain basic level of knowledge related to serious physical ailments as defined by HRA. Collaborates with the wellness health team to develop psycho-educational plans for client’s wellness plan process and medication compliance.
• Maintains updated clients’ case records through the WeCARE wellness care management and HRA platforms, and coordinates effective electronic communication throughout all provider databases, as needed. Maintains case records in accordance with the wellness care management policies/procedures, agency standards and regulatory requirements.
• Participates and consults with team supervisor in case conferences, staff meetings, and discharge planning meetings to determine if client requires an alternate level of care or is appropriate for discharge.
• Participates in special projects and performs other duties as assigned.

Qualifications

Education:

• Bachelor's Degree in a human services or related field required
• Master's Degree program in human services or related field preferred

Work Experience:

• Minimum of two years of experience providing direct services to seriously mentally ill patients/clients required
• Effective oral/written/interpersonal communication skills required
• Bilingual skills preferred, and may be required as determined by operational needs.
• Basic computer skills required