• Complete a comprehensive health assessment/reassessment inclusive of medical/behavioral/rehabilitative and long term care and social service needs.
• Complete/revise an individualized patient centered plan or care with the patient to identify patient’s needs/goals, and include family members and other social supports as appropriate.
• Consult with multidisciplinary team on client’s care plan/needs/goals.
• Conduct outreach and engagement activities to assess on-going emerging needs and to promote continuity of care and improved health outcomes.
• Consult with primary care physician and/or any specialists involved in the treatment plan.
• Prepare client crisis intervention plan.
• Coordinate with service providers and health plans as appropriate to secure necessary care, share crisis intervention and emergency information.
• Link/refer client to needed services to support care plan/treatment goals, including medical/behavioral health care; patient education, and self help/recovery, and self management.
• Conduct case conferences with an interdisciplinary team to monitor and evaluate client status.
• Advocate for services and assist with scheduling of needed services.
• Coordinate with treating clinicians to assure that services are provided and to assure changes in treatment or medical conditions are addressed.
• Monitor/support/accompany the client to scheduled medical appointments.
•  Follow up with hospitals/ER upon notification of a client’s admission and/or discharge to/from an ER, hospital/residential/rehabilitative setting.
• Facilitate discharge planning from an ER, hospital/residential/rehabilitative setting to ensure a safe transition/discharge that care needs are in place.
• Notify/consult with treating clinicians, schedule follow up appointments, and assist with medication reconciliation.
• Link client with community supports to ensure that needed services are provided.
• Follow-up post discharge with client/family to ensure client care plan needs/goals are met.
• Develop/review/revise the individual’s plan of care with the client/family
• Consult with client/family/caretaker on advanced directives and educate on client rights and health issues, as needed
• Meet with client and family, inviting any other providers to facilitate needed interpretation services.
• Refer client/family to peer supports, support groups, social services, entitlement programs as needed.
• Identify resources and link client with community supports as needed
• Collaborate/coordinate with community base providers to support effective utilization of services based on client/family need.
• Maintains complete, current and accurate member files which comply with The Health Home Standards.  Documents all member related activity in a progress note by the conclusion of the next business day.
• Frequent or occasional driving of personal vehicle for purpose of transporting clients in the community and/or site visits (client or work related)
• Other duties as requested.

SKILLS/COMPETENCIES:

• Effective verbal and communication skills
• Ability to teach and influence others
• Demonstrated ability to work effectively in a team environment.
• Demonstrated effective interpersonal relationship and customer services skills
• Good organizational and time management skills
• Ability to work effectively with people from diverse cultures and socioeconomic conditions.
• Actively listens to others to understand their perspective and ensure understanding regardless of barriers.
• Homelessness or chemical dependence. Experience with families preferred.
• Critical thinking ability
• Ability to handle protected health information (PHI) in a manner consistent with The Health Insurance Portability and Accountability Act of 1996.
• Knowledge of computerized systems.
• Knowledge of local and surrounding area resources