Provides care management for clients in collaboration with the Wellness case management team consistent with WeCARE and the VNS Home Care policy and requirements of the Wellness Care Management program. Facilitates the coordination of services between the varying providers for clients with complex psychiatric and/or co-morbid medical conditions who are deemed to be temporarily unable to work. Ensures efficient and successful access and linkage to the full array of necessary physical and behavioral health services. Coordinates effective communication between all providers to the ultimate benefit of the patient. Works under close supervision.

The WeCARE Wellness Program, funded by the Human Resources Administration, provides coordinated care for clients with medical or behavioral health conditions who are temporarily unable to work. After a clinical assessment, eligible clients are assigned to a care manager who maintains a caseload of 70 clients and provides monthly follow-ups. Care managers connect clients to essential treatment providers and community resources to help stabilize their condition. The program includes support from wellness health coaches, who conduct outreach, facilitate workshops, and assist the care management team, as well as an operations team that ensures smooth program delivery. We also have Qualified Health professionals, such as licensed social workers, who complete clinical assessments and manage clients who need enhanced case management. Lastly, the leadership team consists of program coordinators, an operations supervisor, and the directors. The wellness plan typically lasts 90 days, with the option to extend as needed. At the end of the plan, medical documentation is reviewed by on-site physicians to determine whether the client can transition out of the program into a vocational rehabilitation service, requires an extension, or should be considered for Supplemental Security Income.

What We Provide

• Referral bonus opportunities

• Generous paid time off (PTO), starting at 20 days of paid time off and 9 company holidays 

• Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life and Disability

• Employer-matched 401k retirement saving program

• Personal and financial wellness programs

• Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care and commuter transit program

• Generous tuition reimbursement for qualifying degrees 

• Opportunities for professional growth and career advancement and CEU credits

What You Will Do

• Reviews and utilizes completed medical and mental health assessments from the ResCARE clinical team when initiating the wellness plan for clients on the temporarily unable to work track. . Confirms acuity level of identified client and tailors services plan accordingly.
• Develops and monitors wellness plan on behalf of clients with untreated or unstable medical and/or mental health conditions adversely affecting the level of employability. Coordinates and integrates a written, coordinated wellness plan in cooperation with the client the client’s family, and/or other providers serving the client.
• Performs and maintains effective care management for a caseload of clients, as assigned, from wellness initiation to wellness completion. Meets with assigned clients to monitor progress and compliance with the wellness plan. Tracks/ monitors client progress and produces/maintains detailed, accurate and timely case notes. Reviews cases for completeness of documentation.
• Develops inventory of resources that will meet the clients’ needs as identified in the assessment process. Becomes familiar with service providers in the community where the clients resides in order to mitigate barriers to wellness plan compliance such as transportation, childcare etc.
• Provides linkage, coordination with, referral to and follow-up with appropriate ongoing service providers. Participates in meetings with service providers to coordinate service and follow up to ensure client’s compliance with and timely completion of the wellness plans and required documentation.
• Works collaboratively with team members to provide outreach (Via Phone calls, Emails, Texts and Field visits) to clients who have failed to comply with the process of the initiated wellness plan and wellness care management services.
• Provides information and assistance through advocacy and education to client/family on availability and eligibility of entitlements and community services. Assists with arranging escorts and transportation for clients to appropriate facilities/agencies, as necessary.
• Participates in initial and ongoing trainings as necessary to maintain basic level of knowledge related to serious physical ailments as defined by HRA. Collaborates with the wellness health team to develop psycho-educational plans for client’s wellness plan process and medication compliance.
• Maintains updated clients’ case records through the WeCARE wellness care management and HRA platforms, and coordinates effective electronic communication throughout all provider databases, as needed. Maintains case records in accordance with the wellness care management policies/procedures, agency standards and regulatory requirements.
• Participates and consults with team supervisor in case conferences, staff meetings, and discharge planning meetings to determine if client requires an alternate level of care or is appropriate for discharge.
• Participates in special projects and performs other duties as assigned.