• Assures that Health Home (HH) enrollees receive needed medical, behavioral, and social services with the overarching goal of improving individual health outcomes • Assumes overall responsibility and accountability for coordinating all aspects of the individual’s care • Provides Care Management Services at various Community locations and Member’s homes • Leads multidisciplinary teams of medical, mental health, chemical dependency treatment providers, social workers, nurses and other care providers toward assuring enrollees receive services • Explores with the enrollees their immediate needs and their longer term goals and vision for their recovery • Assesses needs, monitors progress with enrollee/legal representative and care team, modifies or updates the care plan or goals • Assists in scheduling and keeping appointments, advocates and arranges for needed services and monitors delivery of services • Evaluates care needs at transitions, arranges safe transition plans, updates care team, updates information with providers and care plans • Activities including promoting self-management, facilitating family/legal representative meetings, seeking peer supports and educating enrollees of their rights • Identifies community networks and supports that will be utilized to address needs

　　Minimum Salary: 37,000Maximum Salary: 39,000Salary Unit: Yearly