• Conduct comprehensive assessments to identify an individual’s clinical and psychosocial needs, choices, and preferences for services 
• Assess and address health and safety issues as well as barriers to care and treatment including social determinants of health
• Collaborate with interdisciplinary team and incorporate input into comprehensive assessment and the person’s Life Plan
• Facilitate, develop, and maintain a person-centered Life Plan that integrates an individual’s personal wants and needs, clinical and non-clinical healthcare related needs, community services, OPWDD services, and natural supports. 
• Incorporate health promotion and support opportunities for individuals to achieve and maintain optimal health and wellbeing
• Adhere to Incident Management regulations, guidelines, and policies and procedures 
• Coordinate and ensure access to chronic disease management
• Facilitate referrals to clinical and community resources, including planning, implementation, and follow-up for comprehensive care management and transitional care
• Participate in internal and external audits
• Coordinate and provide access to long-term care supports and services 
• Engage families and natural supports in the care coordination process
• Provide all individuals and families with services that are culturally and linguistically appropriate 
• Advocate on behalf of the individual
• Promote self-advocacy and the ability to self-direct
• Use Health Information Technology for documentation, to link services, and facilitate communication among care coordination team
• Secure all health records and other protected information with the highest regard to confidentiality and HIPAA laws and regulations
• Maintain compliance with all state and federal laws and regulations, Medicaid compliance, and PCC policies and procedures
• Document all services and maintain appropriate records following all established documentation policies and procedures
• Complete all required training including annual, ongoing, and educational trainings 
• Perform all other duties relevant to the position as requested.

• Ability to act quickly, assess and act accordingly in crisis situations
• Intermediate technology skills in Outlook, Teams, Word, Excel, online applications as needed 
• Understanding use of an EHR system 
• Knowledge of ethical and professional responsibilities and boundaries
• Demonstrate professional work habits including dependability, time management, organization, autonomy, and productivity
• Some positions may require bi-lingual skills

• Bachelor’s degree with two years of relevant experience OR 
• A license as a Registered Nurse with two years of relevant experience, which can include any employment experience and is not limited to case management/service coordination duties OR
• A Master’s degree with one year of relevant experience.

Relevant experience consists of any paid or volunteer experience in the human services field (e.g. Office of Mental Health, Office of Addiction Services or Supports) or providing direct care or support, coordination, or advocacy for people with developmental disabilities on a regular basis.