Provides routine (journey-level) case management work. Work involves reviewing and tracking case management activities; and other work involves developing and maintaining long-term contact with clients, client families, and service providers for social and related service needs under the care coordination program. May train others. Works under general supervision, with moderate latitude for the use of initiative and independent judgment. Reports to: Director II of Area Agency on Aging and/or Program Supervisor II. Interviews and screens clients or authorized representatives to gather information to assess service needs and identify appropriate services to meet the identified needs. Develops and implements service plans to meet clients’ needs. Coordinates service provider and program activities. Provides ongoing case management and serves as a liaison between clients, client families, and service providers. Identifies problem areas, service gaps, and areas that are barriers to services for clients. Maintains case history and progress records, and prepares reports. Monitors clients’ progress. Performs transition planning to ensure continuity of care and management of risk factors.Develops a comprehensive service plan based on client needs, monitors service delivery, reassesses appropriateness, and continuation of services at various intervals. Submits all appropriate documentation to Contract Technician to assure compliance with the fiscal management of the billing process. Adheres to applicable federal/state regulations including, but not limited to, laws related to client confidentiality, release of information, and HIPPA requirements.May train others. Knowledge of community resources; of case management principles, objectives, standards, and methods; and of program policies and procedures. Skill in developing, implementing, and monitoring service and treatment plans. Ability to assess clients’ needs, to coordinate clients’ services, to communicate effectively, and to train others. Effectively communicate in English and Spanish is preferred.