• Conducts initial and ongoing assessments on new members/enrollees and completes the required assessment tools and computer data entry.

• Conduct field visits to assess an older adult's physical, social, emotional and environmental status to determine their eligibility and needs in their homes in accordance with contract compliance.

• Collaborates with the SCO RNCM to develop community care plans.

• Supports and advocates for person centered planning.

• Arranges, coordinates and authorizes the provision of appropriate non-medical services.

• Finds resources and services in the community that support members independence and wellness.

• Monitors the outcomes of the developed community care plan.

• Acts as a liaison between the SCO and many ASAP disciplines.

• Participates in the organization and promotion of health-related programs and activities.

• Attends Primary Care Team meetings and Member Discharge Meetings as required.

• Participates in Team meetings, Managed Care Clinical Meeting, Managed Care Staff Meetings, and activities as a team member.

• Work collaboratively within the team when difficult scenarios and issues arise within a teammate's caseload.

• Other duties as assigned by Managed Care Program Manager

BA/BS in social work, human services or related field plus experience with Elders in a Health Care setting strongly preferred. Associates Degree with significant relevant work experience may be substituted for a portion of degree. Strong written, verbal, and computer skills necessary to work successfully in an interdisciplinary team required. Must have valid Driver's License and reliable transportation. Bilingual in Spanish/Khmer are strongly preferred.