Care Managers bridge the gap between health systems and community-based aging services. Care Managers work with health systems and providers to identify and serve older adults and their informal caregivers that would benefit from programs and opportunities that are available within the community. Care Managers offer a holistic assessment of the client’s needs by identifying health, financial, emotional, functional and environmental concerns. Care Managers offer care options, solutions and guidance maneuvering through challenging systems.


1.0 Provide care coordination/system navigation for referred patients/clients.

1.1 Accepts referrals from medical practice, home care agency or other health system provider.
1.2 Completes comprehensive in-home assessments to determine needs.
1.3 Creates and implements care plans that meet patient/client needs and preferences.
1.4 Maintain close communication with patient/client’s primary care physician to provide informed care.
1.5 Monitors care plans.
1.6 Reassesses patient/client needs and revise care plans as needed.
1.7 Provide information and referral, advocacy, benefit and entitlement counseling.

2.0 Arranges mental health interventions for older adults and their caregivers, when necessary.

2.1 Conducts depression and anxiety screenings, when appropriate.
2.2 Screens for caregiver stress, when applicable.
2.3 Provides supportive counseling to older adults and their caregivers.

3.0 Participates as a member of the inter-agency team.

3.1 Participates in all mandatory Lifespan staff meetings and training’s.
3.2 Participates in all applicable primary care office/health system interdisciplinary meetings.
3.3 Participates in Quality Assurance activities.
3.4 Accepts and seeks guidance and clinical supervision.

4.0 Maintains up to date professional knowledge of the geriatric field, community services entitlement benefits, clinical skills and competencies through reading, workshops and conferences.

5.0 Is aware of and actively supports the Agency’s initiative of being collaborative and community focused, innovative and culturally competent.

6.0 Other duties as assigned by supervisor.


EDUCATION: Master of Social Work degree preferred. Bachelor of Social work required.
EXPERIENCE: Two years in social work, with at least one-year experience in geriatrics. Bilingual preferred but not required.


• Must be able to meet with clients in their homes.
• A portion of the work is performed at a desk or at a personal computer station.
• Verbal, written and telephone communication skills are required.
• Strong written and computer skills needed.
• Interface with all levels of personnel.
• Ability to maintain composure under strict deadlines and difficult situations.
• Ability to work in multi-cultural situations.


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