Primary Responsibilities:** + Serve as the primary care manager for dual eligible members + Engage people face-to-face and/or telephonically to complete a comprehensive needs assessment or wellness assessment (as appropriate), including assessment of medical, behavioral, functional, cultural, and social drivers of health (SDoH) Develop and implement individualized, person-centered care plans inclusive of goals, opportunities and interventions aligned with a person's readiness to change to support the best health and quality of life outcomes by meeting them where they are in their health journey + Partner and collaborate with the internal care team, providers, and community resources/partners to implement care plans and remove obstacles so the member can successfully stay in or return to the community (when appropriate + Assist members with obtaining necessary HCBS supports and services + Provide referral and linkage as appropriate and accepted by the individual being served (may include internal consult opportunities such as Housing Navigator, Pharmacy Team, Peer Specialist, etc. or community-based provider referrals such as PCP, specialists, medication assisted therapy referrals, etc.) + Support proactive discharge planning and manage/coordinate care transition following ER visit, inpatient or Skilled Nursing Facility + Provide education and coaching to support member self-management of care needs and lifestyle changes to promote health + Advocate for people and families, as needed, to ensure that the member's needs and choices are fully represented and supported by the health care team + Support Provider and Facility nonclinical questions (credentialing, claims, etc.) connecting them to the correct Health Plan and/or UHC resources You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. **Required Qualifications:** + Current and unrestricted Idaho license in one of the below: + RN + LCSW, LMSW, LSW, LCPC, LPC, LMFT, LAMFT + 1+ years of experience working with people that have Medicaid / Medicare or who have significant social drivers of health (SDoH) needs + 1+ years of experience with MS Office, including Word, Excel, and Outlook + Driver's license, access to reliable transportation and the ability to travel within assigned territory to meet with members and providers up to 50% of time depending on member and business needs + Access to a designated quiet workspace in your home (separated from non-workspace areas) with the ability to secure Protected Health Information (PHI) + Reside in a location that can receive a UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service **Preferred Qualifications:** + Two-year degree and 2+ years of experience, preferably as a Healthcare Paraprofessional + CCM certification + Experience working with an electronic health records (EHR) system for documentation + Demonstrated experience / additional training or certifications in care in rural settings homelessness, food insecurity, behavioral health, co-occurring conditions, IDD, Person Centered Care, Motivational Interviewing, Stages of Change, Trauma-Informed Care + Experience supporting individuals with complex and chronic conditions including those residing in a nursing facility or that meet nursing facility level of care within the community + Demonstrated background in Managed Care + Experience working in team-based care + Bilingual in Spanish or other language specific to market populations + Reside in Idaho *All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc.