• Engage members telephonically to complete a comprehensive needs assessment, including assessment of medical, behavioral, functional, cultural, and socioeconomic needs •Evaluates disparities in care; develop a plan to address to reduce disparities; implement the plan to address inefficiencies; and coordinate, monitor, and support the needs of each enrollee including caregiver/family •Assesses/identifies enrollee and family in unmet health and social needs and intervenes through connections with outside resources to promote self-care. • Develop and implement person centered care plans to address needs including management of chronic health conditions, health promotion and wellness, social determinants of health, medication management and member safety in alignment with evidence-based guidelines • Partner and collaborate with internal care team, providers, and community resources/partners to implement care plan.• Provide education and coaching to support member self-management of care needs and lifestyle changes to promote health • Support proactive discharge planning and manage/coordinate Care Transition following ER visit, inpatient or Skilled Nursing Facility (SNF) admission • Advocate for members and families as needed to ensure the member's needs and choices are fully represented and supported by the health care team•Facilitate transition of care conversations with enrollee and family and coordinate referral to palliative or hospice services as needed •Serves as a point of contact, advocate, and informational resource for enrollee, family, care team, payers, and community resources and facilitate and attend meetings between enrollee, family, care team, payers, and community resources, as needed •Ensures effective tracking of test results, medication management, and adherence to follow-up appointments.•Utilized computer software systems to effectively document and track outcomes. Computer systems include; SalesForce, ICUE, Provider Portal, etc

• Identify social determinants of health, complete SDOH assessment, and provide appropriate resources, while utilizing federal, state, and local resources to enhance member functionality, quality of life outcomes, and access to quality care • Member of the SME (Subject Matter Expert) Team, as team liaison for social workers. Assists with creating, discussing, and implementing department assignments, projects, and meeting agendas• Completes training and mentoring of all new social work hires• Participated in the collaboration and development of job aides, training material, and department processes• Navigated, utilized, and documented in company databases like TrueCare, ePRG, DataRap, Genesys, FindHelp, Passenger Portal, MIIMS, GPS, eCW, RightFax, Adobe, Teams, SharePoint, etc• Participate in monthly social work meetings to discuss companywide best practices • Coordinate with external and internal teams to minimize obstacles and increase patient and provider satisfaction• Completing medical record requests and reviewing relevant documents • Complete HEIDS gap closure calls to ensure members are receiving adequate healthcare• Met and exceeded daily quality and quantity measurements for call center

Provide direct supervision for all case managers, patient navigators, peer support, and outreach workersMonitor program outcomes to ensure grant compliance through internal auditsReview client files to ensure compliance with Ryan White Standards of CareCompleted annual performance evaluations for care coordination staffTriage client situations and scheduling with appropriate staff and programsFacilitate monthly multi-disciplinary meetings with local Infectious Disease clinicsProvide linkage support to partnering agenciesExtensive knowledge and coordination of public and private insurance programsProvide direct training to all care coordination staffProvide de-escalation support for disgruntled clientsProvide support, as needed, for alternative departments such as, food pantry, transportation, housing, dental clinic, and preventionHiring, promoting, and terminating of staff within department

Provide ongoing non-medical and medical case management services for HIV positive clientsDetermine client eligibility and referred clients to internal and external servicesMaintain case load and worked in collaboration with the doctors and medical staff at AIDS Healthcare FoundationCoordinate medical referralsManage public and private insurance benefits for medical services and medication prescriptionsReviewed Electronic Health Record to monitor lab work, medication adherence, and pending medical referralsWork collaboratively with multiple HIV clinics in the Tarrant County area, including, AHF, John Peter Smith Hospital and Preventative Medicine ClinicCreate needed intervention and follow-up plansProvide agency documentation and case notesCase management trainer for new employees and internsParticipate in agency fundraising events; Member of the HIV/AIDS Walk Committee and Employee Advisory Committee

Assessment, Intervention, Referral Services (AIRS) team member for crisis hotlineWorked with youth in shelter, while assisting and facilitating group activitiesOn-call crisis responder for homeless and runaway youth for national Safe Place ProgramAssisted with court mandated skills group for adolescents, young adults, and familiesFacilitated intakes for ACH servicesCompleted routine follow-up with clients and familiesCarried a case management case load within the LIFE Project, which coordinated services for youth graduating out of the foster care system, while also assisting youth with developing life skillsAssisted with researching, writing, and executing the DFPS HOPES contractProvided agency documentation and case notes in Evolv computer system

In home aide for clients living in the residential community, group homes, supervised apartments, and respite care servicesProvided support and over site of daily programming for clients living with intellectual and developmental disabilitiesAdministered daily medications for residentsProvided education to residents to improve daily living and functional skills for employment, independent living, and social community involvementAssisted with recreational events such as day habilitation, arts and crafts, exercise programs, summer camp, dances, field trips, church services, and community outingsAssisted in the cooking, bathing, and home cleaning responsibilities for the residents