assesses and evaluates member needs and requirements to achieve and/or maintain optimal wellness state by guiding members/families toward and facilitating interaction with resources appropriate for the care and wellbeing of members
Provides specialized support for members receiving Long Term Services and Support (LTSS), with a focus on addressing health-related social needs (HRSNs), providing psychosocial support, and ensuring LTSS meets the member's service needs
May support members residing in NFs by building relationships with facility staff, advocating for member care (including access to needed behavioral health services)
Contacts members telephonically and face-to-face to establish goals and priorities, evaluate resources, develop plans of care, and identify LTSS providers and community partnerships to provide a combination of services and supports that best addresses the needs and goals of members and caregivers through person centered thinking approaches
Focuses on supporting members and/or caregivers utilizing an interdisciplinary approach in accessing long term services and support, social, housing, educational and other services, regardless of funding sources to meet their needs
Develops and modifies Individual Service Plans and involve applicable members of the care team in care planning (Informal caregiver coach, PCP, etc.)

Bachelor's degree in social sciences, social work, human services, or a related field
Two (2) years of prior experience working with Medicare and Medicaid recipients, long-term care services, Home and Community-Based Services (HCBS), and/or managed care organizations
One (1) or more years of professional experience working with members in custodial and transitional care
Ability to use a variety of electronic information applications/software programs including electronic medical records
Valid state driver's license and maintain personal vehicle liability insurance
Bilingual or Multilingual: English/Spanish, Arabic, Vietnamese, Amharic, Urdu or other
Must be able to speak, read and write in both languages without limitations and assistance.

medical, dental and vision benefits
401(k) retirement savings plan
time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave)
short-term and long-term disability
life insurance

Care Coach – Transition, Custodial Prevention

Key skills