Provided crisis intervention services when necessary by assessing risk levels and promptly addressing safety concerns collaboratively with the treatment team. ●Established and maintained relationships with clients, families, and community partners to coordinate services to meet client's needs. ●Managed complex caseloads, ensuring timely assessment, intervention, and documentation for optimal care outcomes. ●Managed approximately 30 incoming/outgoing calls, emails, and text messages from clients daily. ●Facilitated family meetings to address concerns, establish goals of care, and provide psychosocial support. ●Communicated with healthcare providers to facilitate continuity of care. ●Arranged transportation and documented details of discharge transition plans. ●Promoted patient self-management by providing education on chronic condition management and healthy lifestyle choices. ●Maintained detailed records in compliance with agency standards and regulations. ●Participated in team meetings and training to stay updated on best practices and new developments in care management. ●Cordinated referrals to specialists, hospitalizations, E.R. visits, ancillary testing, and other enabling services for patients. ●Conducted thorough assessments to identify patients' needs, strengths, and barriers to achieving optimal health outcomes. Read less