POSITION PURPOSE: Maintains an active caseload of clients who need extensive care management and supportive oversight on a temporary basis. POSITION REQUIREMENTS / QUALIFICATIONS: Education/Experience: Graduate from an accredited college or university with a Bachelor of Science or Arts Degree in the Social Work, Psychology, Human Services, Nursing, Science or Health field. Minimum of six months' experience working in the field of social work or case management. Familiarity with the local community resources. Licensure / Certification: CPR Certificate from the American Heart Association. Valid Florida Driver’s License. Skills / Ability: Verbal and written fluency in English. English required bilingual desirable. POSITION RESPONSIBILITIES (THIS IS A NON-EXEMPT POSITION):  Maintains an active caseload of clients who need case management services and extensive oversight on an ongoing basis.  Implements ongoing monitoring of clients’ needs, and evaluation of services to ensure collaborative care among the Population Health staff, interdisciplinary team members and outside service constituents.  Exercise and promote a functional referral system with all departments within CHI system to ensure quality care.  Network with various external resources to provide services for patients as needed.  Ensure active caseload of patients have an appropriate interdisciplinary staff especially with center nursing team to ensure patients are successfully transfer within 6 weeks no later than 8 weeks for management.  Maintains records of services provided to clients and completes records for funding programs, also assisting with gathering and compiling information for internal and external reports  Participates in patient/community education (internal and external) and home visits when necessary.  Communicates pertinent information to supervisor / appropriate staff.  Participates in Quality Assurance Program and continuing education as required.  Maintains all licenses and/or certificates as required for the job.  The Population Health Care Management Specialist must monitor clients’ adherence to treatment and medication regimens.  Encourage individuals to become involved in consortium activities.  Participate in any other functions to meet the goals of this activity.  The Population Health Care Management Specialist must collaborate with other caregivers (i.e. medical care provider, nutritionist, prescription drug provider, etc.) for adherence and assistance in meeting treatment objectives.  The Population Health Care Management Specialist will also be expected to empower clients to be actively involved in the development and monitoring of their treatment and adherence plans and must ensure that immediate follow-up is available for clients who miss their prescription refills and/or who experience difficulties with adherence.  Maintains and meets monthly productivity standards.  Reports to work on time and ready to work with minimal absenteeism.  Completes B&E (billing and encounter) forms within the same day of intervention.  Provides accurate and timely documentation in patient charts within the same day of intervention.  Adheres to Confidentiality Policies and Procedures / HIPAA Regulations.  Performs other duties as assigned.