Outreach & Case Management

the incumbent will provide comprehensive case management activities for elders, disabled adults, and their families.


Elderly Services Program

Pay Grade:

$11.25 - $13.00 DOE



Job Description:

Under the general supervision of the Elderly Services Program Director, the incumbent will provide comprehensive case management activities for elders, disabled adults, and their families to improve their quality of life and provide access to resources both locally and regionally to maintain the highest level of functionality so clients may age in place within the community. Incumbent will also provide outreach services to introduce potential clients to program services, resources, and educational forums related to programs goals and objectives. Incumbent must effectively interpret program services and perform tasks directly related to community elder clients (aged 50 years and older).  Services will focus on the enhancement and improvement of daily lifestyles of the elder population. Incumbent will be required to work with and interpret a variety of service reports and data bases (i.e. SAM’s, OAAPS, etc.). Incumbent will be required to work with other program staff and organizational programs in capturing and recording data and information related to elder clients, their stated needs, and in the planning and scheduling of outreach and educational activities. The position requires a high level of visibility within the community which requires excellent communication and interpersonal skills which are vital in maintaining a rapport with elders, the general public, and agencies providing services. Incumbent’s contacts will include but are not limited to Tribal Council, Tribal Administration, Tribal Programs staff, Federal, State, and County agency representatives, elders of the community, and the general public.


·       Facilitates client access to community and agency resources including but not limited to activities and services to establish social support networks, meet individual and family needs such as housing, food, clothing, assistive devices, and assist in accessing services to address emotional/mental health wellbeing;

·       Coordinates and monitors services which include comprehensive tracking of client activities and services provided according to client needs and care plan.

·       Assists clients and families in developing goals and care plans in areas of identified needs. This includes providing interpretation, guidance and preparation for assistance/support applications. Conducts regular follow up to ensure goals are met and care plans are followed.

·       Conducts initial assessments/intake for new clients, and annual/6 month re-assessments for enrolled clients to ensure regular updates on client information and care plans.

·       Documents all client encounters, and contacts made on behalf the client(s). Maintains comprehensive client files which includes management of formal and confidential documents held for safe keeping on behalf of the client.  Respond to information access and retrieval requests from authorized individuals following all stated confidentiality guidelines.

·       Conduct outreach to the elder population to promote participation with the Elderly Services Program. Promotional activities include but are not limited to public education, group presentations, health fair participation, and development and dissemination of flyers, brochures, and newsletters.

·       Determines program needs through target group assessments and works with the Activities Planner to plan/coordinate events which enhance the quality of life for all elder and disabled adult participants.

·       Work with resource agencies on coordinated service provisions to promote the expansion of existing programs for social support, and educational activities for all enrolled clients and their families. 

·       Identify, collaborate, and coordinate with Elderly Services program staff and other tribal program staff in determining all available services and make appropriate referrals for client care and needs.

·       Manage the public relations for the Elder Services Program through the development of fliers, social media posts, and program brochures/newsletters. Provide up to date program and service information to all Homebound and Congregate elder clients. 

·       Coordinate with program staff and other programs to plan onsite information and assistance through workshops and sessions for elder clients in areas such as health education, health screening, injury prevention, social services, and behavioral/mental health services, etc.

·       Compile client/service information, and prepare a variety of reports as requested and/or directed by the Program Director.

·       Develop and maintain automated data bases, spreadsheets, and graphics using various software packages in support of Program activities, operations and grant proposals.

·       Attend meetings concerning client services and other federal, state, or county meetings relating to the Elderly Services Program as directed.  May be required to attend evening and/or weekend meetings.

·       Establish and maintain contact with families of program participants to ensure communication of the elder client’s needs and serves as a liaison between the client, the family, and internal/external agencies providing services. Interpret for both the client and the family when necessary. 

·       Assist in scheduling appointments for clients, and assist program staff with follow-up cases to ensure that care plans are carried out and regularly evaluated. Interpret, support, and advocate for elders.

·       Participate in all emergency drills and environmental safety activities.

·       Attend and participate in grantee-sponsored trainings, program pre-service and in-service trainings, and other continuing education, career and professional development opportunities.

·       Participate in the program's self-evaluation process and grantee monitoring visits and comply with any applicable Program Improvement Plans that are developed.

·       Participate in general staff meetings and other meetings, conferences, and events planned by the grantees, and the program director.

.        Assist the Activities Planner as directed by the Program Director, in providing transportation and physical assistance services to elders for special functions and activities held off site. 


·   Education:  High School diploma or general education degree (GED); and two years related experience and/or training in social work or community services. It is preferred that the incumbent have some level of knowledge or training in working with maintaining databases/programs and working with the elderly population to provide translation and interpretation in the Keres language which allows for accurate data collection.  

Knowledge, Skills & Abilities:

To perform the duties of this position successfully, an individual must be able to perform each essential duty effectively.  The requirements listed are a viable assessment of knowledge, skills, and abilities necessary for job performance.  Reasonable accommodations may be made to enable individuals with special needs, limitations and/or disabilities to perform the essential functions: 

·       Knowledge of the rules and regulations related to the confidentiality of sensitive client and program information. Some knowledge of HIPPA regulations related to confidentiality and strict adherence to maintaining client information.

·       Knowledge and strict adherence to Tribal, State, Federal and Local Policies and Procedures governing all facets of operating a compliant and effective Elderly Services Program.
·       Knowledge of community and external resources and services available for the elderly population.
·       Ability to communicate effectively with employees, elders, agency representatives, medical providers, and the general public using tact, courtesy, and common sense.
·       Ability to monitor, assess, and track/record client progress against the care plan and make changes necessary to meet the client’s needs. Must have the ability to present progress and changes in writing and orally.
·       Ability to establish and maintain effective working relationships with employees, elders, agency representatives, and the general public. Must be able to positively respond to stressful situations involving elder client services.
·       Must possess strong interpersonal, problem solving, planning, time management and organizational skills.
·       Must have the ability to exercise extreme patience and sensitivity while working with the elder population; and have the ability to resolve conflicts effectively. 
·       Knowledge of records management and maintenance techniques; ability to read, translate, and interpret documents. Knowledge of office administration functions.
·       Ability to understand and execute oral and written instruction. Knowledge of basic grammar, spelling, punctuation, and required formats. Must possess effective written and verbal communication skills.
·       Demonstrated expertise in operating standard office equipment such as computers, typewriters, calculators, fax machines, and copy machines. Ability to utilize and apply software such as word processing, spreadsheets, graphics, desktop publishing, internet access and retrieval and database management.
·       Ability to work independently in a fast paced environment, manage a high volume of work, set priorities and meet deadlines.
·       Knowledge of basic rules, procedures, and practices for correspondence preparation and control, mail distribution, filing systems, records management, travel regulations, and other administrative functions.
·       Ability to maintain a high level of accuracy in preparing and entering information with attention to detail.
·       Knowledge of the Customs and Mores of the Pueblo of San Felipe and willingness to adhere to the practices with respect.

Working Conditions:

The individual is frequently required to sit for long periods of time. Occasionally required to walk, lift and /or move light to heavy boxes, and equipment when necessary. He/she will be required to escort elderly clients. Must have manual dexterity to enter/retrieve information and compile reports from a computer. Bends and stoops regularly.

Additional Info:

·   Required Licenses/Certifications:


Preferences: Keres language speaker preferred. Demonstrate ability to conduct public speaking and oral presentations on a one on one basis, and/or small group situations to elders, agency representatives, and other employees of the Tribal organization. Must have the ability to speak the Keres language fluently for the purposes of translation and interpretation.

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