* Provide case management, case assistance and the development and maintenance of care plans in English and Chinese languages* Assist clients in the coordination of care and services from various home healthcare agencies, benefit and entitlement agencies and legal and financial providers.* Coordinate services with health professionals including Primary Care Physicians and in-House Program nurse.* Conduct home visits and assessments* Assist in the planning and implementation of new educational and recreational activities for the members and residents of Knickerbocker Village.* Conduct outreach to community

* Handled the tasks of conducting psychosocial evaluations and gathering demographic information with older adults.* Assigned the responsibilities of ensuring patients receive proper medical follow-up details at the time of discharge.* Performed the tasks of follow-up with medical team in health care meetings for the physical and mental complications of the patients.* Performed the responsibilities of implementing innovative plans of discharge or problem-resolution for patients.* Convening town hall meetings to learn the concern and needs of the resident patients.

* Oversaw managed care unit operations and conducted case management screening and biopsychosocial assessment procedures. * Worked collaboratively with interdisciplinary staff, external organizations and community resources to provide health services across the continuum of care.* Provided support in crisis to immediate needs of patients and families in emergency situations.* Facilitate discharge activities and coordination in determining discharge disposition and transportation facilities.

* Assisted clients with SSI, Medicare, Medicaid application and re-certification. * Provided supportive counseling and case management services to tenants Collaborates closely with onsite social workers members on development of appropriate case plans meeting individual client needs.* Co-facilitated support group for senior Chinese tenants of the apartment building.* Organized activities to promote healthcare knowledge and medical policies.

Assisted all patients through the healthcare system by acting as a patient advocate and navigator.* Arranged and ensured healthcare services such as homecare aids, social workers, physical therapists appointments are scheduled and performed. * Coordinated continuity of patient care with external healthcare organizations and facilities, including the process hospital admission and discharge and referrals from the primary care. * Facilitated patient healthcare management based upon standing orders and protocols.