Job Summary

Serves as a key member of the healthcare team and is a primary resource for assisting community members in navigating the broad care system. Provides information about healthy behaviors and uses various approaches to support community members in reducing health-related risk behaviors in culturally competent ways that communities will understand and accept. Recognizes the importance of addressing the social determinants of health in guiding, supporting and assisting community members to live healthier lives. Works closely with medical providers, primary care teams, faith communities and social services agencies to provide short term care coordination and connection to resources and support to improve health and well-being through education and provision of care coordination.

Essential Functions

• Engages a population of socially vulnerable community members in their care, assisting them through the process of working towards better health by providing support, encouragement, and education in person, by telephone, and via electronic means.
• Engages individuals to maximize strengths to achieve health, social, and personal goals.
• Builds relationships with respect to diversity, using active listening, casual counseling and encouragement.
• Demonstrates and practices skills necessary to carry out effective home visits and/or community events.
• Identifies the elements of healthy lifestyle behaviors and understands the importance of self-management.
• Educates community members on self-management of health conditions and supports patients in developing healthier habits and proper use of the emergency room and providing information for alternatives.
• Based on the community member’s readiness to change, provide customized, evidence-based patient education and self-management support tools in a variety of areas including but not limited to weight management and exercise, tobacco cessation, stress reduction.
• Coordinates and documents including comprehensive tracking of community members' compliance in relation to care plan objectives, non-clinical assessments, client encounters, service plans and outcomes achieved in an effective manner.
• Assists and motivates community members in understanding care plans and instructions.
• Assists community members in accessing health related services, including but not limited to: obtaining a medical home, providing instruction on appropriate use of the medical home, overcoming barriers to obtaining needed medical care and /or social services.
• Follows up with community members and providers regarding health/social services plans.
• Facilitates access to community resources, including locating housing, food, clothing, prenatal classes, parenting, and providers to teach life skills, and relevant mental health services.
• Works to reduce cultural and socio-economic barriers between community members and institutions.

Physical Requirements
Work in a variety of environments; an office environment, a community member’s home environment and/or hospital/school/community agency or settings. Exposure to a medical setting and household conditions as well as communicable diseases could occur. Significant traveling or driving may be required, as well as sitting for moderate periods of time. Ability to lift 20-30 pounds required.

Education, Experience and CertificationsHigh School Diploma or GED required. Bachelor’s degree in a relevant human service field preferred. Strong interpersonal skills and good communication and literacy skills and demonstrate the ability to develop rapport as an active member of the care management team required. Valid NC driver’s license required, excellent driving record and have reliable transportation.