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Job Description Job Purpose JESPY Transitional Coordinators will support the vision and mission of the agency. Transitional Coordinators are responsible for the day-to-day monitoring and transitioning of clients while in the Skill Development, Employee Partnership and Mentorship Phase. While monitoring a client more closely through their respective journeys in the areas of skill development, job partnership and mentorship in job performance, clients have a better chance for success. Coordinators will cross train in all areas of the Client Development Department. Each coordinator will be assigned as needed among the three phases. During Phase I, Skill Development, transitional coordinators focusing on TSITES can be more productive focusing on skill development. During Phase II and III, the transition coordinator will focus on both the Employee Partnership and Mentorship Phase when employment readiness is reached. With the transitional coordinators focusing on both Job Placement opportunities and Mentorship we can provide a better sense of support for clients. Duties and Responsibilities Resource Development for Program Expansion • Prepare clients for a variety of work environments during the skill development phase., • Identify and develops specific job opportunities that match the clients’ skills, work experience and/or training, related training and interests., • Maintains relationships with existing employers and establishes relationships with new employers who are willing to hire disabled and learning disability employees., • Schedules prospecting/cold calls and face-to-face meetings with employers with regard to hiring the learning and developmentally disabled., • Assist in development plan preparation for each client, • Assess physical, attitudinal, communication, transportation and financial barriers. Request accommodations where necessary., • Provide assistance in preparation of resumes, mock interviews, job interviews and job application, and orientation as required., • Observe client on job site and provide training assistance as needed., • Provide immediate feedback and assistance as required to clients regarding job performance as related by employee supervisor., • Provide instruction in self-advocacy., • Provide crisis intervention as required, • Advocate for client regarding job performance and other work related situations as required., • Documents, consistently and accurately, all client and employer contact, activities and outcomes in Foothold., • Attend Foothold training as necessary, as well as, other professional development training., • Advocate on behalf of client in both crisis and job advancement, including salary, work conditions, and benefits., • Responsible for input of current employee changes, including pay rate work address, supervisor and promotion or termination, for all clients, both DDD and non DDD clients., • Report all contact (with description, i.e., reason for contact, result, regarding which client if applicable, date and time, as well as, name of contact, result and next steps/and or progress of client) of prospective employment partnerships and clients daily. Competencies • Putting People First, • Building and Maintaining Positive Relationships, • Demonstrating Professional, • Supporting Good Health, • Leadership, • Problem Solving, • Ensuring Safety Both on Site and In the Community, • Supporting Independence and Growth Reporting and Financial • Document all billable services as per DDD/Medicaid via Foothold, • Monthly tracking/reporting of client mentorship activity relative to client management Activity Coordination Assist in the organization and implementation of two Job Opportunity Fairs per year. This event will bring together private, corporate and nonprofit organizations interested in hired the learning and developmentally disabled population. Outreach Interact with community relative to the awareness and opportunities for learning and developmentally disabled population. Other Responsibilities • Other responsibilities that may arise within the job scope Qualifications Education Requirement: 2 years’ experience working in related field Must complete 12 hrs. continuing education credits as DDD requirement via the College of Direct Support Must complete 8 hrs. additional continuing educational credits in areas of “best practices” Mandatory Competency-Based Training: DDD Shifting Expectations Prevention of Abuse, Neglect and Exploitation DDD Life Threatening Emergencies (Danielle’s Law) Additional Minimum Competencies Required DSP Professionalism Professional Documentation Practices Working with Families Supporting Jobs and Careers in the Community Employment Supports Cultural Competence Work Experience Requirement: 2 plus years’ experience working with adults with learning and developmental disabilities. Skills/Abilities/Minimum Competencies: Excellent communication skills and ability to foster community partnerships and relationships with people across a spectrum of intellectual and developmental disabilities. Ability to exercise sound judgement and respond quickly to crises and emergencies; ability to prevent or minimize crises. Conflict resolution skills. Excellent computer skills including a working knowledge of MS Word, Excel. Special Working Conditions/Physical/Requirements Must be available for coverage on some weekends and after 5pm when required. Valid driving license is required. Direct Reports N/A

Job DescriptionPosition: Inpatient Care Manager The Inpatient Care Manager reports directly to the Market Physician Executive (MPE) within their Pod and is responsible for engaging with Monogram’s attributed patients and their families in inpatient facilities. This role’s primary responsibility is to find, engage and enroll new patients in the Monogram program. However, this person will also spend time visiting currently enrolled patients who are hospitalized and provide support with discharge planning or social services. The Inpatient Care Manager might also complete these activities occasionally for patients in outpatient settings, such as dialysis centers or primary care clinics. In all these situations, the Inpatient Care Manager will need to be empathetic, inquisitive and resourceful to identify and solve for the patient’s unique needs. In many instances, this person will need to coordinate with hospital or payer staff to gain access and reach these objectives. The Inpatient Care Manager must be confident and able to overcome barriers to access facilities and patients. This person will attend their Pod’s daily concurrent review rounds, to stay apprised of newly admitted patients and build their work queue for the day. The needs of the Pod’s change frequently so it’s important that the Inpatient Care Manager maintain a tight working relationship with their MPE, Market Administrative Coordinator (MAC) and Clinical Performance Lead (CPL). Roles and Responsibilities • Attends daily concurrent review rounds with Pod clinical leaders and works with their manager to build a daily work queue, • Reviews inpatient and emergency room admission data through Monogram’s care events, • Conducts pre-visit research to better understand each patient’s background and potential needs, • Drives to and finds patients in facilities to engage with them and facilitate enrolling them in the Monogram program, • Assesses patient’s cognitive status to ensure effective communication, and verifies patient identification and contact details for HIPAA compliance, • Articulates Monogram’s services and value in an accurate and compelling manner, while respecting boundaries of the patient and family, • Ability to engage and build rapport with patients, family and caregivers of diverse socio-economic and cultural backgrounds with multiple chronic conditions and vulnerabilities, • Applies evidence-based criteria to determine clinical intervention eligibility and recommend next actions to Pod leadership, as needed, • Identifies social services and discharge planning needs and works with the patient, family and hospital staff to access resources, • Serves as an informational resource for patients and families/caregivers regarding their care plan and available services (hospice care, palliative care, long-term acute care, home care, etc.), • Evaluates patient’s progress and effectiveness of resources or services, making necessary and appropriate changes based upon patient’s status, • Reviews patient consent status and obtains new consent, if required, • Practices within the scope of licensure Position Requirements, • Graduate from an accredited Social Worker or Registered Nurse program of study, • Current active Social Worker or Registered Nurse (unrestricted) licensure, • Minimum of two (2) years’ previous care management experience, • Ability to demonstrate empathy, compassion, and quickly build relationships with patients, family/caregivers, and care teams, including physicians, • Ability to handle rejection and keep trying, while respecting patient’ and families’ boundaries, • Ability to navigate hospital environments, advocate for access and maintain composure when faced with resistance from hospital staff, • Experience assessing vulnerable high-risk patients and advocating for their needs to external staff at hospitals or payers, • Demonstrated verbal and written communication skills, • Previous experience with electronic health record platforms, MS Office Suite, and mobile phone and web-based applications, • Reliable personal transportation, valid driver’s license, and auto insurance, • Must live in the desired geography and be willing to travel 2-3 hours per day to visit patients, • Ability to work independently with minimal supervision as well as part of a team, • Demonstrated initiative and self-starter, • Infrequent domestic travel may be required, primarily to Brentwood, TN Benefits, • Opportunity to work in a dynamic, fast-paced, and innovative care management company that is transforming the delivery of kidney care., • Competitive salary and opportunity to participate in company’s bonus program., • Comprehensive medical, dental, vision and life insurance, • Flexible paid leave & vacation policy Monogram Health employs a robust clinical team, leveraging specialists across multiple disciplines including nephrology, cardiology, endocrinology, pulmonology, behavioral health, and palliative care to diagnose and treat health issues; review and prescribe medication; provide guidance, education, and counselling on a patient’s healthcare options; as well as assist with daily needs such as access to food, eating healthy, transportation, financial assistance, and more. Monogram Health is available 24 hours a day, 7 days a week, and on holidays, to support and treat patients in their home. Monogram Health’s personalized and innovative treatment model is proven to dramatically improve patient outcomes and quality of life while reducing medical costs across the health care continuum. Monogram Health is based in Nashville, Tennessee, operates throughout 37 states, and is privately held by Frist Cressey Ventures, Norwest Venture Partners, TPG Capital, as well as other leading strategic and financial investors. To learn more about Monogram Health, ranked by Inc. Magazine as 2024’s No. 3 fastest growing private company in the United States, please visit here. At Monogram Health we believe in fostering an inclusive environment in which employees feel encouraged to share their unique perspectives, leverage their strengths, and act authentically. We know that diverse teams are strong teams, and welcome those from all backgrounds and varying experiences.

Job Description Wellness Social Worker (LSW) Status: Full Time Hours: 35 hours per week Schedule: 11:00 am – 7:00 pm Reports To: Director of Community Wellness or Director of Behavioral Wellness Compensation: $65,000 – $75,000 commensurate with experience Benefits: Health, Dental, 401K Matching, Paid Time Off Role Overview The Wellness Social Worker is a vital, full-time position responsible for advancing the health, wellness, and social-emotional needs of youth and families within the Boys & Girls Clubs of Newark (BGCN) community, specifically supporting the READY Family Wellness Center (RFWC) programs. This role involves direct service, clinical case management, program leadership, trauma-informed practices, training, and community engagement to ensure members can thrive. About the Boys & Girls Clubs of Newark (BGCN) Founded in 1938, BGCN is a leading non-profit organization dedicated to enabling all young people-especially those who need us most-to reach their full potential as productive, caring, responsible individuals. We serve youth ages 5–18 through comprehensive afterschool and summer programs focused on academic success, character and citizenship development, and healthy lifestyles. RFWC encompasses the Children's Dental Center, Wellness Center, and Vision services, providing holistic support to our members and the greater Newark community. Required Qualifications • Master's degree in Social Work and Licensed Social Worker (LSW) required., • Minimum 1–2 years in a related social work role or youth development setting., • Ability and interest in supervising BSW/MSW practicum students; SIFI certification preferred or willingness to obtain certification., • Enthusiastic commitment to BGCN's mission, trauma-informed care, youth development, and strength-based approaches., • Proven ability to engage authentically and effectively in multi-cultural and cross-cultural settings; deep understanding of how race and identity intersect with practice., • Strong supportive counseling and group facilitation skills; excellent interpersonal, assessment, mediation, and conflict resolution skills., • Highly organized, efficient, self-aware, and adaptable in fast-paced environments., • Strong computer literacy: Microsoft Office, Outlook, Google Suite., • Knowledge of metrics and outcome evaluation. Essential Duties & Responsibilities Direct Service & Clinical Case Management • Maintain a caseload of Tier 2 clients, providing individual and small-group supportive counseling to enhance psychological well-being and social-emotional functioning., • Conduct and document assessments, behavioral observations, and service planning; ensure accurate documentation compliant with HIPAA and confidentiality regulations., • Implement evidence-based and culturally responsive interventions to support member goals, redirect challenging behaviors, and resolve conflicts., • Review relevant records (IEPs, 504 Plans, etc.) to inform comprehensive service planning., • Other duties assigned as needed. Program Leadership, Supervision & Professional Development • Supervise Wellness interns and ensure a high-quality, professional learning environment., • Provide consultation and support to staff and supervisors during youth-related crises, including de-escalation guidance and follow-up planning., • Support staff development by contributing to team huddles, monthly trainings, and on-site coaching., • Serve on BGCN's Care Team, supporting partnerships with the National Child HELP Partnership and contributing to the development of an evidence-based trauma-informed support network for BGCN and Newark families., • Other duties assigned as needed. Family & Community Engagement • Lead family support efforts including resource referrals, parent coaching, and teaching stress management and coping strategies., • Coordinate family engagement events in collaboration with Program Directors and Site Coordinators., • Serve as a liaison between BGCN/RFWC and external partners; conduct outreach to promote wellness services., • Develop targeted communications, resources, and materials for families and community partners regarding RFWC services., • Other duties assigned as needed. Trauma-Informed Practices & National Training Initiatives The Wellness Social Worker plays a key leadership role in advancing BGCN's trauma-informed framework and supporting BGCA's National Trauma-Informed Training Initiative. Organizational Trauma-Informed Leadership • Serve as an active member of BGCN's Trauma-Informed Team, contributing to the development, refinement, and implementation of trauma-informed practices, policies, and environments across all Club locations., • Model trauma-informed principles-safety, trust, empowerment, collaboration, cultural humility, and equity-in all interactions with youth, families, and staff., • Coach staff in understanding the impact of trauma on youth behavior, learning, and relationships; support staff in implementing co-regulation, restorative responses, and de-escalation strategies., • Participate in program observations to ensure the integration of trauma-informed practices and identify opportunities for improvement and coaching., • Other duties as