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About the roleResponsible for evaluating and managing the psychosocial aspects of identified cases within the clinical program. Supports the clinical management analyst in managing complex cases. Optimizes resources to the community available to the policyholder. Provides intensive social work support in identified cases of members who meet enrollment criteria, focusing on members who are complex, high, moderate, and low risk. Develop strategies to change behavior or cope with difficult situations; and they refer patients to other resources or services, such as support groups or other mental health professionals. Develop treatment plans with the patient, doctors, and other healthcare professionals and may adjust the treatment plan if necessary, based on their patient’s progress.What You'll Do- Evaluates the psychosocial aspects of cases referred and discusses the findings with the care team. - Performs on site visits for social needs evaluation.- Coordinates mental health services with third parties.- Develops an individualized work plan as part of the patient’s care plan, based on identified social problems and needs. - Provides support and consultation to the patient, so that can adjust adequately to temporary and permanent changes caused by illness and treatment.- Provides caregivers with information and best practices to support patients in their attainment of their goals.- Helps with cases in the process of application and acquirement of services offered by agencies and community resources.- Collaborates in the fulfillment of recommendations established in the care plan.Identifies and maintains relations with community resources and agencies committed to offering services and care to vulnerable. Serves as liaison, and refers cases, as necessary.- Complies with established outreach goals.- Documents interventions in the care management tool and follows up with members until their goals are attained.- Works in a team-based care clinical environment, including adhering to established clinical protocols; actively participating in team meetings (“huddles”) as established by the clinic physician and proactively share patient clinical outcomes and progress with other team members.- Prepares production reports, statistics and presentations when required.- Document interventions in the care management tool and follow up members until their interventions finalize.- Comply with established daily, weekly, and monthly outreach goals.- Other tasks as assigned by management and that are essential.