Bilingual

• Maintain ongoing caseload of individuals through the utilization of evidence based approaches to promote engagement and achievement of health goals
• Use relationship-based strategies to support members with social support navigation
• Conduct periodic telephonic and SMS outreach to ensure timely follow-up to members
• Work with member to identify health/wellness goals and incorporate goals into Health Action Plan/Shared Care Plan
• Support nurse care manager, behavioral health care manager, nurse practitioner and Community Engagement Specialist with delegated tasks
• Collaborate on care issues with Enhanced Care Management team by participating in systematic case reviews and consulting before taking clinical actions
• Consistently meet monthly encounter metrics to ensure compliance with health plan regulations
• Identify and break down barriers ensuring individuals’ continuation with the program
• Assist individuals in securing connection to community supports by scheduling appointments, managing referrals, and ensuring timely follow-ups
• Coordinate physical care management appointments through collaboration with external and internal providers
• Utilize external and internal online platforms to collaborate with team members and carry out daily tasks
• Role is primarily remote (~90% work from home) with 1-2 times per month on-site community visits near candidate's city

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