• Conducts telephonic outreach to assigned members to assess health, environment, nutrition, and psycho-social areas of concerns using a variety of assessments. • In response to assessments, coaches and problem solves with member to identify and address specific goal(s) to support health and behavior change. • Provides appropriate interventions to optimize health and well-being. Interventions may include education, the coordination of community-based support services, and other resources. • Charts member's treatments and progress in accordance with state regulations and department procedures. • Makes referrals to case manager, as appropriate, and/or refers member's family to community support services and resources. • Provides home assessment to high-risk members and develop an individual care plan. • Collaborates with physicians in screening and evaluating members for psychotropic medications. • Understands the clinical program design, program monitoring and reporting. • Practices as an interdependent member of the health team and provides important components of primary health care through direct social work services, consultation, collaboration, referral, teaching, and advocacy. • Assess and treats outpatients in individual and family modalities exercising mature professional judgment and using a wide range of social work skills to include individual and family counseling to assist patients and their families in dealing with chronic and acute diseases/injuries. • Conducts psychosocial assessments to determine patient needs and resources (both family support and community support). • Provides counseling to patient and family in matters directly related to patients’ limitation, adjustment to medical condition, and ongoing treatment. • Develops and implements discharge plans, follow-up care, and transfers to other health care facilities (e.g., nursing homes, rehabilitation hospitals, etc.). • Provides consultation services to medical, nursing, and ancillary hospital staff regarding psychosocial issues, discharge plans, and follow-up care for patients and families. • Provides crisis intervention services. • Responds independently, and with various media, to appropriate community requests. Takes the initiative in seeking out opportunities to present programs to meet the needs of patients/members and their families. • Consults with Hospital administration, and Plan supplying information and feedback regarding procedures and services provided by the Psychology Division. • Develops and maintains working relationships with community resources. Coordinates with physicians, and representatives of their service disciplines for the benefit of the member and their families. Takes initiative in identifying and assessing the needs of the community and organizes responses to address those needs. • Interfaces with the RN Case Manager(s) and the Interdisciplinary Team (IDT) in the development and implementation of the Case Management Program (CMP). • Integrates social work case management and nurse case management as a team.