Job Details

Job Description
Job Description

As a key member of our care team, you will engage with members in person-either at a facility or in a community setting-as well as virtually over the phone. You will support members by assessing their overall health and wellness, helping them set meaningful goals, and guiding them toward healthier lifestyles through personalized, compassionate care.

Key Responsibilities:

• Establish meaningful connections with members through face-to-face or telephonic interactions.
• Conduct comprehensive assessments that address members' biopsychosocial, functional, and behavioral health needs.
• Apply motivational interviewing techniques to help members uncover intrinsic goals and inspire positive behavior change.
• Practice active listening to gather relevant information and respond dynamically during assessments.
• Encourage active participation in the assessment process and collaboratively develop individualized plans of care that reflect each member's goals, needs, and preferences.
• Identify urgent or high-risk situations and escalate appropriately to ensure timely intervention.
• Partner with members to define health goals and identify barriers that may impact goal achievement.
• Provide education on health and wellness topics to support self-management and improved outcomes.
• Work collaboratively with members to develop practical solutions to overcome barriers to care.
• Identify and connect members to appropriate community resources based on identified needs.
• Present complex case details to the interdisciplinary care team and integrate their input into care plans as needed.
• Utilize computer applications (e.g., Microsoft Excel, Word, Outlook, Office Communicator) to document and share member-related information.
• Accurately and promptly document assessments, interactions, referrals, and follow-up plans in relevant systems.
• Stay current with updates and changes to computer systems and effectively apply knowledge in day-to-day work.
• Meet or exceed performance metrics within a virtual, productivity-driven environment.

• Deep passion and commitment to supporting individuals with complex medical, behavioral, or social needs.
• Bachelor's degree in Social Work, or license as a Licensed Practical Nurse (LPN), Certified Nursing Assistant (CNA), or Home Health Aide (HHA) preferred.
  
  
  • Alternatively, a high school diploma or equivalent with a minimum of 3 years of experience in a community health or healthcare setting, or demonstrated experience using motivational interviewing techniques.
• Must be fully vaccinated against COVID-19.
• Proficiency with Microsoft Office products, particularly Word and Outlook; ability to quickly learn and navigate clinical or member-related applications.
• A dedicated, private home workspace with secure, high-speed internet access via cable or DSL.
• Valid driver's license, active auto insurance, and reliable transportation for occasional field visits to members, hospitals, or community locations.
• Residency within the Philadelphia, PA area is required.

• Bilingual proficiency (spoken and written).
• Formal training or demonstrated skill in motivational interviewing.