Position SummaryCommunity Health Specialists connect/link patients that have barriers to care, support preventive aspects of health, assists patients in accessing psychosocial and/or health services and support patient empowerment through health education and coaching. Community Health Specialists develop and maintain collaborative relationships with community key stakeholders, gatekeepers and other community organizations, assist patients in navigating health care and social transitions, and support patient empowerment through health education and coaching.Core Job Responsibilities• Engage patient assigned or referred for community health specialist in a collaborative on-going relationship to help facilitate their care• Promote programs and services for families and provide health care and social information that encourages self-management• Market ACCESS programs and services and empower people to engage in the health programs• Educate on basic medical illness, diseases and/or behavioral health needs.• Assess patient’s strengths and needs and develop a plan for intervention. Care planning and coordination is done in collaboration with an interdisciplinary team• Provide ongoing follow-up with patients and/or service providers to determine whether patients have accessed services. Follow-up should be continuous from initial identification through case closure.• Make home visits and conduct case management activities in community settings as required by program guidelines• Conduct or co-lead group interventions as required by program guidelines• Serve as part of the patient’s care team and support health center operations and attainment of organizational metrics• Establish effective and respectful relationships with patients, families, professionals, payers and other relevant parties• Assist in developing/maintaining community referral relationships and effectively connecting patients and families to community resources• Engage in community planning groups and/or meetings to support the social and health care needs• Using information systems and decision support, maintain a risk-adjusted caseload, and provide direct case management services to address specific issues affecting their health risk or health status• Complete documentation and data entry as needed to assure optimal patient care and program reporting – track outcomes of outreach efforts• Participate in evaluating outcomes at the individual level with each patient and at the same time participate in agency-wide evaluative and quality improvement efforts• Obtain & maintain certifications/licensure/trainings as needed• Perform other duties assignedRequirements/Preferences• High School diploma required; Bachelor’s degree preferred in a health-related field (social work, psychology, counseling, rehabilitation, gerontology, sociology, or other human service field).• Minimum one (1) year case management experience or two (2) years of experience in a public or private social service program or health care setting.• Demonstrated knowledge of working in a community based or public health setting.• Basic familiarity with medical terminology• Intermediate proficiency with Microsoft Office products (specifically, Word, Excel, Outlook)