Overview

Provides education, client advocacy, regular evaluation and feedback about clients on caseload. Assist with client's evaluation to determine their eligibility for other social service programs. Alerts team members when follow-up is required and ensures efficient and successful access and linkage to the full array of community based services with the goal of client's successful completion of the care plan. Works under close supervision.

Compensation Range:$15.79 - $19.73 Hourly

• Reviews rosters to identify clients that require follow up and assistance. • Provides a care plan to the client and care management team; notifies and assists of any immediate needs and risk factors and makes referrals to services to address such needs. • Coaches members by providing motivational interviewing techniques and skills to address medical and psycho-social health. Motivates and supports client to participate in their individualized care plan. • Provides outreach via phone to clients for a follow up on self-care, medication fills/refills, care plan engagement/adherence scheduled visits, and test results received from providers. • Reinforces education provided by client’s medical providers related to the management of the chronic disease or conditions specified in their care plan; helps educate clients about conditions and self care/condition management. • Provides health coaching and support of assigned clients from initiation into program to completion. Works closely with the care management team to discuss clients’ progress in plan and goals for completion. • Provides information and assistance through advocacy and education to client/family on availability and eligibility of entitlements and community based services. Assists with client navigation of health system. • Prepares detailed, accurate and timely case notes and utilizes care management platform as required to note client progress and updates. • Works collaboratively with team members to provide outreach for and engage resistant clients with overdue screenings or upcoming appointments and /or who have been non-compliant with necessary treatment appointments. • For CMO: • Assists with general program support in areas of technology such as CarePort, Interactive Voice Response (IVR) Remote Patient Montiring andTiger Text. • Assists in arranging clients who have been unresponsive to the care management team. May provide canvasing efforts to locate client. • Assists clients in obtaining MD appointment. • For Wellness Program: • Uses motivational interviewing techniques and skills to identify substance use history and symptoms related to care plan. • Provides guidance on self-management tools. • Facilitates periodic case record reviews and case conferences with all providers serving the client. Reviews new cases for completeness of documentation. • Participates in special projects and performs other duties as assigned.

Qualifications

Licenses and Certifications:
License/Certification from a Community Health Organization required

Education:
High School Diploma or equivalent required Associate's Degree in Human Services or related field preferred

Work Experience:
Minimum of one year experience in care management, community health, social service, or medical practice preferred Basic computer skills preferred Effective oral/written/interpersonal communication skills required Bilingual skills may be required as determined by operational needs.