Job Description

Duties and Responsibilities

• Conduct comprehensive assessments of medical, behavioral health, and psychosocial needs.
• Identify risks for adverse health outcomes such as hospitalization, emergency visits, or functional decline.
• Develop individualized, person-centered Plans of Care based on client goals, strengths, and barriers.
• Implement and monitor care plans in collaboration with clients and interdisciplinary care teams.
• Review and update care plans regularly based on progress and changing needs.
• Provide health education and self-management support.
• Promote self-advocacy, independence, and wellness.
• Support clients in navigating insurance benefits and eligibility requirements.
• Advocate for timely access to care and removal of service barriers.
• Coordinate care following hospitalizations, emergency visits, or other critical events.
• Facilitate communication among primary care providers, specialists, behavioral health providers, and community supports.
• Maintain accurate, timely, and audit-ready documentation.
• Conduct home visits and community visits as required.
• Collaborate with families, caregivers, and service providers.

Qualifications

• Bachelor’s degree in Social Work, Psychology, Human Services, Nursing, or related field.
• Minimum 2–3 years of experience working with adults in behavioral health, care coordination, case management, or community health.
• Strong organizational, communication, and problem-solving skills.
• Ability to work independently and within multidisciplinary teams.
• Experience in Medicaid care management programs.
• Knowledge of serious mental illness, substance use disorders, or chronic medical conditions.
• Bilingual in Spanish preferred.