Overview Provides, education, client advocacy, regular evaluation and feedback about clients on caseload. Also evaluates clients' 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.
What We Provide
R eferral bonus opportunities
Generous paid time off (PTO) , starting at 2 0 days of paid time off and 9 company holidays
Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life and Disability
Employer-matched retirement saving funds
Personal and financial wellness programs
Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care and commuter transit program
Generous tuition reimbursement for qualifying degrees
Opportunities for professional growth and career advancement
Internal mobility, CEU credits, and advancement opportunities
Interdisciplinary network of colleagues through the VNS Health Social Services Community of Professionals
What You Will Do
- Uses rosters and meets with the team members to identify clients that require follow up and assistance.
- Reviews care plan with the client and care management team; notifies and assists the care management team of any immediate needs and risk factors and makes referrals to services to address such needs.
- Utilizes 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 and in person community visits to clients to follow up on self-care, medication fills/refills, care plan engagement/adherence scheduled visits, and test results received from providers.
- Reinforces education provided by clients 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 for a caseload of assigned clients from initiation into program to completion. Works closely with the care management and team to discuss clients progress in plan and goals for completion. Prepares detailed, accurate and timely case notes and utilizes care management platform as required to note client progress and updates.
- 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. Arranges transportation and accompanies clients to facilities/agencies, as necessary.
- Works collaboratively with team members to provide outreach for and engage resistant/hard to reach clients with overdue screenings or upcoming appointments and /or who have been non-compliant with necessary treatment appointments.
- For Wellness Program:
- Uses motivational interviewing techniques and skills to identify substance use history and symptoms related to care plan.
- Provides escorts to visits in the community in an effort to increase participation in an adherence to Wellness Plan and related appointments.
- Provides self-management tools and reviews how to use those tools. Conducts voluntary Wellness Groups on site at WeCare. 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.
Education:
- High School Diploma or equivalent required
- Associate's Degree or Bachelors degree in a human services or related field preferred
Work Experience:
- Minimum of one year experience in care management, community health, social service, or medical practice preferred
- Effective oral/written/interpersonal communication skills required
- Basic computer skills required
- Bilingual skills may be required as determined by operational needs.