Field Care Coordinator - Licensed Social Worker or LPN - Remote in Shelby County, TN

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As part of a care management team who will manage a caseload of complex members, the Field Care Coordinator will be the primary care manager for elderly and/or disabled members with complex medical/ behavioral health needs. Care coordination activities will focus on supporting member’s medical, behavioral, and socioeconomic needs to promote appropriate utilization of services and improved quality of care. This is a home-based position with field responsibilities. If you are located in Shelby County, TN, or the close surrounding areas, you will have the flexibility to work remotely* as you take on some tough challenges.

Serve as primary care manager for elderly and/or disabled members who live in individual housing, community-based housing (ALF or CLS homes) or nursing facilities Engage members and/or their families face-to-face and/or telephonically to complete a comprehensive needs assessment, including assessment of medical, behavioral, functional, cultural, and socioeconomic (SDoH) needs Develop and implement individualized, person-centered care plans inclusive of goals, opportunities and interventions aligned with a person’s readiness to change to support the best health and quality of life outcomes by meeting the member where they are Partner and collaborate with internal care team, providers, and community resources/partners to implement care plan Provide referral and linkage as appropriate and accepted by member (may include internal consult opportunities such as Housing Navigator, Pharmacy Team, Peer Specialist, etc. or community-based provider referrals such as PCP, specialists, medication assisted therapy referrals, etc.)