Conduct evaluations of Member's individual psychosocial, environmental, cultural, health access, medicalneedsCoordinate, facilitate, monitor plan of care to achieve optimal clinical, financial outcomesOversee discharge planning, facilitate safe transitions to community settingsPlan, execute interdisciplinary, patient/family conferences as necessary to formulate, communicate plan ofcareServe as liaison between members of interdisciplinary care team, community providers, payers sources,patient/family to ensure safe, effective plans, smooth transitions between internal, external level of careMaintain professional relationship with payer representatives, assist in resolving any utilization issues thatariseAdvocate for Member's care needs within healthcare delivery system and associated servicesAssure timely performance of utilization management processes to maintain compliance with Federal, State,and Managed Care contract regulations

Provide home based psychosocial assessments, and service plans to restore patient to optimum social andhealth adjustment within patient's capacityConnect and advocate for patients who have psychosocial barriers, physical illnesses, developmentaldisabilities and connect them with local community resourcesCounseling/ Crisis interventionMaintain and build relationships with physicians, case managers, hospitals, long term care, independent andassisted living facilities and other community resourcesAdvance directives (Power of Attorney for Health Care or Living Will)Streamline workflow, prioritized tasks, allowing increase in home visits, patient contact and number ofevaluations completedAttend conferences, clinical events and workshops to meet and network with other community organizationsCoordinate and follow up on community referrals and transitions for patients

Administrative oversight and supervision of grant funded case management programs, supportive serviceprograms and teamsHired and supervised staff providing direct services to individuals struggling with Domestic Violence issues,HIV, incarceration, undocumented immigrants & family/pediatric casesManaged approximately 30 employees throughout several programsProvided chart reviews and monitored all assessments, behavioral modification plans, service plans, caseclosing summaries and discharge plansRepresented and served as agency liaison for program at AIDS Institute and Department of Mental HealthExpanded program outreach by delivering talks to community organizationsMaintained thorough and accurate records outlining program operations and participant progressConferred with upper leadership to understand and meet diverse needs, providing frequent feedback onfront-line operations and recommending improvement strategiesProvided onsite training

Provided support & guidance on ongoing basis to new Social Work team regarding client crises, assessmentsand interventionsCompleted psychosocial assessment to obtain comprehensive knowledge of participants' vocational potential,medical, mental health barriers, cultural and/or special needsDeveloped and implemented outcome-oriented service plans customized toward individual participants inconjunction with interdisciplinary teamArranged and advocated for provision of servicesAssisted Healthcare team with discharge planning processResolved emergent situations that arise with participants including but not limited to suicidal and homicidalideations, threats, etc

Supervised 10 staff members & trained college interns.Advocated for clients in Court & Social Service agencies.Conducted family assessments, individual, group and family counseling sessions.Devised interventions and strategies for individuals and families.Drafted curricula and protocol for operation of peer support groups.Worked in conjunction with interdisciplinary team (NYS Parole & Department ofProbation).Maintained and prepared charts, case notes, and activity reports.Planned and organized fund raising and community events.