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

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About the role

Become a part of our caring community   $5,000 Sign-On Bonus: Subject to applicable terms and conditions. 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 • 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. Use your skills to make an impact   $5,000 Sign-On Bonus: Subjec

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