• Provide long-term care management to frail, economically disadvantaged, culturally diverse older adults, disabled adults and caregivers in order to help them remain safely at home and to prevent premature institutionalization • Assess new clients and determine appropriateness for the MSSP program, certify the client as nursing home eligible, conduct assessments and reassessments for identification of client’s medical, physical, and psychological needs • Ensure client’s needs are met through written care plan approved by the program supervisor and discussed verbally with the client and/or his representative • Provide ongoing health education to non-clinical staff members • Present cases at and participates in weekly team case conference per guidelines • Discuss during case conference complex health care issues for teaching purposes • Contact client’s physician as needed to discuss health problems identified during assessments • Provide education to the client or family member regarding topics including self-care, hygiene, and nutrition • Collaborate with staff, clients, physicians, home health, community services, family members, hospital discharge planners, and other professionals involved in the care of the client to assure appropriate services, and safe living environment below the cost of a skilled nursing facility • Maintain monthly documentation of clients along with other clinical documentation of relevant contacts with clients, service providers, health professionals, or other community agencies in a timely manner • Maintain accurate purchase of service records by completing accurate and timely monthly service authorizations and verifications to contracted vendors and following contract guidelines for service expenditures • Develop and implement care plans for assigned caseload • Help to maintain census and provide excellent customer service in the community by participating in ongoing outreach activities • Participate regularly in Quality Assurance chart reviews, completing other audits as required, helping to train new employees, participating in training sessions, and responding positively to suggestions for improvement • Increase knowledge by keeping current on Medicare and Medi-Cal policies, Federal and State legislation affecting health and social services, maintaining updated community resource information, attending trainings as scheduled, actively participating in supervision, and striving to improve professionally • Other duties as assigned.