The challenges of affordable healthcare continue to create new opportunities. Elderplan and HomeFirst, our Medicare and Medicaid managed care health plans, are outstanding examples of how we are expanding services in response to our patients' and members' needs. These high-quality healthcare plans are designed to help keep people independent and living life on their own terms. Provides telephonic assessments of members’ medical, psychosocial, physical, and spiritual needs. Utilizes completed UAS-NY assessments to develop a Person-Centered Service Plan (PCSP). Responds to changes in members’ condition/sentinel events (i.e. level of care changes, changes in family support, changes in housing, etc.) by revising the PCSP and communicating changes with interdisciplinary care team and PCP. Responds to requests for service within Medicare/Medicaid regulated time frames utilizing appropriate correspondence as per DOH/CMS regulations and departmental workflows. Participates in and presents cases at the Interdisciplinary Care Team meetings to discuss any changes in member’s condition/sentinel events (i.e. level of care changes, changes in family support, changes in housing, etc.) identified during assessment process. Collaborates with interdisciplinary care team members, such as Primary Care Physician, Social Worker, Specialists, Hospice/Palliative team, and Chief Medical Director when complex social/medical focus areas are identified during the assessment/care planning process as per unit workflows. Educates members on Advanced Directives/Health Care Proxy/Power Of Attorney (POA) and helps to facilitate the completion of such documentation. Bachelor’s degree social work or related field required, MSW or LMSW preferred. Minimum three to five years clinical social experience in long term care, managed care, home care, geriatrics or hospice preferred. Prior experience in an interdisciplinary service delivery environment preferred. Working knowledge of Medicare and Medicaid regulations preferred. Prior experience in an interdisciplinary service delivery environment preferred. Current LMSW in New York State preferred.