1. Resources, Education & Training

• Attend staff meetings, case management department meetings, in-service training programs, and case conference meetings.
• Assist with implementation of quality management/improvement and evaluation.
• Facilitate case consultations with the Interdisciplinary Team.
• Engage in relevant activities.

2. Intake and Assessments

• Identify appropriate clients for case management through eligibility screening and intake; maintain client eligibility requirements as per contract.
• Document assessments with clients to evaluate their needs.
• Ensure timely entry of services delivered into the appropriate database within 24 hours of engagement.

3. Service Plan

• Develop a comprehensive, client-centered service plan in collaboration with the client to address needs and goals.
• Empower clients to become involved in their own planning and goal setting.
• Evaluate and adjust plans as needed to achieve positive outcomes and improve the quality of life.
• Ensure timely entry of services delivered into the appropriate database.
• Link clients to needed resources via inter-agency and intra-agency referrals and document linkages and progress in the electronic health/medical record system.

4. Monitoring and Follow-Up

• Contact clients on a monthly basis or more frequently as needs arise or per contract requirements.
• Maintain thorough, current, and confidential records of each client, including the ongoing service plan.
• Maintain accurate records of food, transportation, and equipment installation services provided.
• Ensure timely entry of services delivered into the database.
• Follow up with clients to ensure the implementation of the service plan achieves desired quality-of-life outcomes.

5. Advocacy

• Assist clients and/or families with completing necessary applications for community services and public benefits.
• Provide appropriate service referrals and resources for the client and advocate on their behalf to improve accessibility.
• Coordinate and network with other agency/community resources to ensure the provision and delivery of needed services.
• Assist clients in problem-solving, providing counsel and advocacy to encourage access to medical care, food programs, emotional support services, legal assistance, risk prevention equipment, and other services.
• Facilitate communication and coordination between medical case management, nutrition, psychosocial, and housing providers.

6. Other

• Provide guidance to assigned interns and/or volunteers in the provision of service delivery.
• Facilitate and/or organize client support groups, including educational seminars or events, if needed.
• Participate in community meetings and represent the agency at community events.
• Prepare monthly, quarterly, and annual service reports for case management.
• Reconcile service units against productivity rates.
• Demonstrate full commitment to quality assurance and cultural competency.
• Facilitate case consultations with the Interdisciplinary Team.

• Bachelor's degree - preferably Social Work/Psychology/Health Science/Human Services related field
• 1-2 years of experience working with people with disabilities,
  geriatric population and their families, hospice care, respite care and/or hospitals.
• Driver's License and Insurance