Titanium Healthcare Inc.

Bilingual

• Research, establish, and maintain a list of available housing opportunities in the region
• Develop relationships with and knowledge of local community resources, including transitional housing, shelters, and permanent housing
• Develop individualized housing plans and communicate plans and housing opportunities to members
• Ensure services and placements are consistent with member care plans
• Assist members with housing searches, apartment applications, landlord negotiations, and rental applications
• Help members understand tenant rights and responsibilities
• Mediate landlord communications when disagreements or concerns arise
• Conduct follow-up meetings after housing placement
• Maintain accurate documentation of service objectives, outcomes, and member information in appropriate data systems
• Participate in collaborative team meetings and develop best practices
• Follow departmental and companywide policies and procedures
• Comply with safety and injury prevention policies and regulations
• Use the Homeless Management Information System (HMIS) to add members into the housing portal
• Assist members with completing CES assessments
• Assist members in person with assessments or housing tenancy
• Perform other duties as assigned or required by departmental policy

Bilingual Housing Navigator

• Provide support to difficult-to-engage patients and patients with cultural or linguistic barriers through field-based contacts and appointment accompaniment
• Assist the Registered Nurse Care Manager, Behavioral Health Care Manager, and Care Coordinator with delegated panel-management activities
• Support ECM team engagement efforts for eligible patients in clinics and communities
• Help patients navigate healthcare systems and community resources
• Conduct phone and in-person follow-ups with eligible and enrolled ECM patients
• Help patients participate in medical and behavioral healthcare and overcome barriers
• Update the multidisciplinary team and providers on patient barriers
• Engage patients using evidence-based approaches such as motivational interviewing
• Promote collaboration between patients and medical/behavioral teams
• Collaborate with ECM team members on patient care plans
• Participate in weekly systematic and ad hoc case reviews
• Consult with the RN Care Manager or Behavioral Health Care Manager before taking clinical action
• Accompany patients to office visits as needed and within health plan guidelines
• Perform other assigned duties and projects

Bilingual Community Health Worker

• Manage an assigned caseload of adult and pediatric members
• Maintain a caseload of up to 50 members and conduct monthly in-person visits
• Conduct comprehensive assessments of members’ physical, emotional, and social needs
• Develop and tailor individualized care plans based on assessments, medical history, preferences, needs, and goals
• Coordinate communication among healthcare providers, social workers, therapists, and other care team members
• Collaborate with doctors, clinical consultants, housing navigators, and leaders to make member-specific recommendations
• Monitor member progress and update care plans according to policy and compliance requirements
• Ensure prescribed treatments and interventions are followed
• Communicate significant changes and member-status updates to primary care and specialty providers
• Provide member service through telephone and in-person support
• Maintain accurate records of assessments, care plans, and member interactions
• Ensure compliance with relevant regulations and standards
• Complete required documentation accurately and promptly
• Provide leaders with case progress updates
• Advocate for members navigating the healthcare system and accessing services
• Educate members and families about health topics, treatment options, and self-care
• Connect members with community resources, support services, and programs
• Plan and coordinate hospital or long-term-care discharge processes
• Participate in training new employees
• Perform other duties as assigned or required by departmental policy

Bilingual Lead Care Manager

• Manage an assigned caseload of adult and pediatric members
• Maintain a caseload of up to 50 members and conduct monthly in-person visits
• Conduct comprehensive assessments of members’ physical, emotional, and social needs
• Develop and tailor individualized care plans based on assessment findings, medical history, preferences, and goals
• Coordinate communication among healthcare providers, social workers, therapists, and other care-team members
• Collaborate with medical Doctors, Clinical Consultants, Housing Navigators, and Leaders to make member-specific recommendations
• Monitor member progress and update care plans according to policy and compliance requirements
• Ensure prescribed treatments and interventions are followed
• Communicate significant changes in member concerns and status to PCPs and specialty care providers
• Provide positive member client service through telephone and in-person support
• Maintain accurate records of assessments, care plans, and member interactions
• Ensure compliance with relevant regulations and standards
• Complete required documentation accurately and timely according to company standards
• Provide leaders with case progress updates periodically or as required
• Advocate for members by helping them navigate healthcare, understand treatment options, and access services
• Educate members and families on health topics, treatment options, and self-care strategies
• Connect members with community resources, support services, and programs such as housing assistance, financial aid, and counseling
• Plan and coordinate discharge for members leaving hospitals or long-term care facilities
• Participate in training new employees
• Perform other duties as assigned or required by departmental policy

• Manage an assigned caseload of adult and pediatric members
• Maintain up to 50 members and conduct monthly in-person visits
• Conduct comprehensive physical, emotional, and social needs assessments
• Develop and tailor individualized care plans
• Coordinate communication among healthcare providers, social workers, therapists, and care team members
• Collaborate with doctors, clinical consultants, housing navigators, and leaders
• Monitor member progress and update care plans according to policy and compliance requirements
• Ensure prescribed treatments and interventions are followed
• Communicate significant member concerns and status updates to primary care and specialty providers
• Provide member service by telephone and in person
• Maintain accurate records and complete required documentation
• Ensure compliance with relevant regulations and standards
• Report case progress to leaders periodically or as required
• Advocate for members and help them navigate healthcare services and treatment options
• Educate members and families on health topics, treatment options, and self-care
• Connect members with community resources and support programs
• Plan and coordinate discharge transitions from hospitals or long-term care facilities
• Participate in training new employees
• Perform other duties as assigned or required by departmental policy

• Maintain a caseload of up to 50 members and conduct monthly in-person visits
• Review and interview potential members to verify Health Homes Program eligibility
• Complete referrals when necessary
• Orient and educate members and families about the Care Coordinator role
• Initiate care plans and provide education about treatments, procedures, medications, and continuing care requirements
• Collaborate with healthcare professionals, community and social support services, and company employees
• Document care evidence and member encounters in the EHR system
• Check in with members and schedule appointments
• Communicate with providers and care teams about member progress and needs
• Explain and translate care information for members when necessary
• Follow up on referrals to ensure continuity of care and member/family needs are met
• Reassess care plans for effectiveness and desired outcomes
• Address member questions and process requests
• Investigate and direct inquiries or complaints to appropriate staff and follow up on resolution
• Enroll and disenroll members according to established policies
• Maintain knowledge of community resources, including housing, financial assistance, transportation, and food assistance
• Follow protocols for pain, safety, and mental health concerns and create safety plans when necessary
• Recognize and appropriately report child and elder abuse to Child/Adult Protective Services
• Follow departmental, companywide, safety, and injury-prevention policies
• Perform other assigned or required duties

Bilingual Housing Navigator

Bilingual Community Health Worker

Bilingual Lead Care Manager

Bilingual Lead Care Manager

Bilingual Lead Care Manager

Bilingual Care Coordinator