Job Title

To assist with the coordination of all interdisciplinary and ancillary services within the Multi-Assistance Center (MAC), as well as external agencies in support of CommuniCare patients within the MAC. DUTIES AND RESPONSIBILITIES: 1. Engages in basic generalist practice that includes interviewing, assessment, planning, intervention, evaluation, information and referral, problem-solving, consultation, supportive counseling, education, advocacy, and community organization. Uses all appropriate software programs (i.e. electronic health records, MAC client tracking system, etc.) 2. Develops and maintains a cumulative record for each client receiving supportive services as required by professional licensure standards and CommuniCare / MAC policies and procedures. Develops an action plan for each patient, identifying goals based on functional level, physical/medical conditions, support network, psychosocial and financial status based on long and short-term needs. 3. Develops and maintains effective working relationships with individual clients, families, and community partners. Serves as client liaison and advocate. Collaborates with MAC Navigators to determine need for referrals to community agencies and conducts follow-up activities to assess outcomes. 4. Conducts individual and family training in psychosocial management skills. 5. Works as part of an interdisciplinary team to provide integrated behavioral health and primary care services. Communicates effectively with clients, staff, and participants in interdisciplinary teams. Cooperates with and contributes to the development and implementation of an interdisciplinary treatment plan. 6. Promotes interactive communication and develops and refines linkages between CommuniCare and MAC programs, community health care facilities, social service providers, schools, and other agencies. Cooperates with local medical, mental health and community agencies. Maintains documentation of community resources. Participates in community events during business work week, weekends, and evenings as needed. 7. Participates in activities to develop and maintain quality assurance indicators that evaluate the effectiveness of patient interventions. 8. Sustains productivity expectations established by supervisor. 9. Performs other related duties as assigned. JOB QUALIFICATIONS: High School Diploma or equivalent required Bachelor's degree in Social, Human or Community Services or three years' experience may be substituted for degree Ability to plan and organize Ability to perform well under stress Experience with personal computers to include internet/intranet navigation and EHR/EMR Ability to maintain confidentiality at all times Bilingual in English and Spanish preferred Familiar with needs of Special Needs Population Certified in Basic Life Support (BLS), American Heart Association Scheduled hours and/or work locations are subject to change REQUIRED PHYSICAL AND MENTAL ACTIVITIES AND REQUIREMENTS: Finger Dexterity: Using fingers to make small movements such as typing or picking up small objects. Normal fine and gross motor control of fingers and hands. Talking: Frequently conveying detailed or important instructions or ideas accurately, clearly, or quickly. Hearing: Able to hear average or normal conversations and receive ordinary information; hear whispered voice at five (5) feet. Repetitive Motions: Frequently and regularly using the wrists, hands, and fingers. Visual: Visual acuity necessary for the proper evaluation of a patient and to prepare or inspect documents or other materials. Ability to accurately view computer monitors Physical: Sitting 20-30% of time and standing, walking 70-80% of time. Lift up to 25 lbs; push and pull up to 45 lbs. Able to bend at the waist, twist and turn along axial plane.