BILINGUAL Field Care Manager, Social Work (LTSS, HCBS, Waiver programs)

Humana•Chittenden, VT

2d•$65,000 - $88,600•Hybrid

About The Position

The LTSS Bilingual Field Care Manager, Social Worker assesses and evaluates members’ needs and requirements to help them achieve and maintain optimal health, safety, independence, and quality of life. This role guides members and families in accessing resources and services appropriate to their care and well-being. The Social Work Field Care Manager applies person-centered, trauma-informed, and culturally responsive strategies to address members’ functional, behavioral, environmental, and psychosocial needs within Michigan’s Long-Term Services and Supports and Home and Community-Based Services programs. Assignments are varied and frequently require interpretation, sound professional judgment, and independent determination of the appropriate course of action. Bilingual in Arabic and/or Chaldean Neo-Aramaic.

Requirements

Must reside in Michigan and be able to travel throughout the assigned service area, including Wayne and/or Macomb Counties.
Fluent in English and Arabic or Chaldean Neo-Aramaic, with the ability to speak, read, and write each language independently and without assistance.
Active Michigan Social Work license in good standing required (LBSW, LLMSW, or LMSW). Candidates with a limited license must demonstrate active progress toward full licensure.
2+ years of post-degree experience in social work, behavioral health, health care, care management, or community-based services.
1+ year of experience supporting Home and Community-Based Services (HCBS) and/or waiver programs.
Experience conducting Long-Term Services and Supports (LTSS) assessments.
Ability to assess functional, behavioral, environmental, and psychosocial needs to support eligibility determinations, service planning, risk identification, and care coordination.
Knowledge of LTSS, HCBS, Medicaid requirements, person-centered planning principles, member rights, and supporting members in the least restrictive setting.
Experience collaborating with interdisciplinary teams, health care providers, members, caregivers, and community-based organizations.
Knowledge of community health, behavioral health, social service agencies, and local resources.
Demonstrated ability to maintain accurate, timely, and compliant documentation in accordance with organizational, state, and federal requirements.
Strong verbal and written communication skills with the ability to build effective relationships with members, families, caregivers, providers, and community partners.
Proficiency using electronic medical records, care management platforms, and other health care technology applications.
Strong computer skills, including proficiency with Microsoft Word, Outlook, Excel, and web-based applications.

Nice To Haves

Experience conducting InterRAI Integrated Health Care assessments and using assessment findings to inform person-centered care planning.
Knowledge of or experience supporting Nursing Facility Level of Care Determinations in collaboration with licensed clinical staff.
Experience with Medicaid, Medicare, dual-eligible populations, behavioral health, chronic conditions, disability services, or complex care management.
Previous managed care experience.
Experience with health promotion, coaching, wellness, motivational interviewing, and trauma-informed care.
Fluent in English and Spanish, with the ability to speak, read, and write each language independently and without assistance.

Responsibilities

Manage an assigned caseload and complete comprehensive assessments, applying a social work lens to functional, behavioral, environmental, caregiver, and psychosocial findings, with members in their homes or other community-based settings, as well as telephonically or virtually when appropriate.
Conduct comprehensive InterRAI Integrated Health Care assessments to evaluate members’ functional, cognitive, behavioral, environmental, social, and psychosocial needs and support person-centered care planning and LTSS service coordination. Social worker identifies clinical findings that require RN review or intervention.
Contribute to Nursing Facility Level of Care Determination activities within the role’s scope, collaborating with licensed nursing staff when clinical review or medical complexity assessment is required.
Develop, implement, monitor, and modify individualized person-centered care plans in collaboration with the member, authorized representative, caregivers, providers, and other members of the Interdisciplinary Care Team.
Serve as a primary point of contact for the Interdisciplinary Care Team and coordinate with members, care team participants, and external resources to ensure identified needs are addressed.
Assess social determinants of health and identify barriers related to housing, food access, transportation, safety, behavioral health, caregiver support, education, finances, and access to health care and community services.
Coordinate and facilitate access to Medicaid, Medicare, HCBS waiver, behavioral health, medical, social, housing, educational, and other community resources, regardless of funding source.
Support members in receiving services in the least restrictive and most integrated setting appropriate to their needs, preferences, health, welfare, and independence.
Provide ongoing monitoring, care coordination, advocacy, and follow-up to evaluate progress toward care plan goals and identify changes in condition, function, risk, caregiver capacity, or service needs.
Apply person-centered planning, motivational interviewing, trauma-informed care, and culturally responsive engagement techniques to build rapport and support informed member choice.
Identify and escalate urgent health, safety, abuse, neglect, exploitation, behavioral health, or service-access concerns in accordance with organizational and regulatory requirements.
Collaborate with nursing, behavioral health, primary care, specialists, waiver service providers, community agencies, and caregivers to promote continuity of care and reduce avoidable institutionalization.
Complete timely, accurate, and compliant documentation of assessments, care plans, contacts, interventions, referrals, authorizations, and outcomes in designated electronic systems.