Care Coordination RN or Social Worker

About the position Responsibilities • Serve as primary care manager for high medical risks / needs members with comorbid behavioral health needs • Engage members 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.) Requirements • Master's degree in social work or Bachelor's degree in social work, psychology, special education, or counseling with 1+ years of experience in providing case management services to older adults or individuals with disabilities • Current, unrestricted independent licensure as a Registered Nurse in Indiana or Licensed Practical Nurse (LPN) with 3+ years of clinical experience with older adults • 1+ years of experience with local behavioral health providers and community support organizations addressing SDoH • 1+ years of experience with MS Office, including Word, Excel, and Outlook • 1+ years of experience in long term support services or working with older adults • Resident of Indiana - Jackson County, Brown County, Jennings County, Decatur County or Bartholomew County • Reliable transportation and the ability to travel within assigned territory to meet with members and providers Nice-to-haves • 2+ years of experience in long term support services or working with older adults • Experience working in team-based care • Experience in serving individuals with co-occurring disorders (both mental health and substance use disorders) • Demonstrated experience / additional training or certifications in Motivational Interviewing, Stages of Change, Trauma-Informed Care, Person-Centered Care • Background in Managed Care • Bilingual in Spanish or other language specific to market populations Benefits • Flexible work arrangements for residents in specified counties • Opportunities for professional development and career advancement • Recognition and rewards for performance Apply tot his job