Job Summary

Serves as a key member of the health care team and is a primary resource for assisting patients in navigating the care system. Reaches out to patients to provide support in the patient’s adherence to their individual care plan, assisting to identify and remove any logistical, emotional, or social barriers to treatment. Serves as the patients’ primary conduit to the health care provider as they help coordinate necessary services both within and outside the health system.

Essential Functions

• Engages a population of medically vulnerable or chronically ill patients in their care, assisting them through the process of working towards better health by providing support, encouragement and education.
• Communicates and maintains relationships with other members of the Care Management team to promote a lifelong, proactive partnership with patients to enhance and personalize management of health-related needs.
• Completes screenings on patients for social determinants of health needs and refers as appropriate.
• Communicates with patients and caregivers in person, by telephone and via electronic means.
• Utilizes Chronic Disease Management protocols, under the direction of clinical teammates; monitors patient-reported biometrics, medication adherence, reported challenges/barriers and promptly connects the patient with the appropriate resources, and/or notifies the patient’s care team for additional follow-up.
• Provides customized, evidence-based patient education in a variety of areas, under the guidance of clinical teammates and based on the patient’s readiness to change; includes but not limited to weight management/exercise, tobacco cessation, stress reduction and chronic disease self-management. Uses Motivational Interviewing skills to engage and assist patient/parent/family.
• Assists providers’ offices/ medical home staff with member specific missed appointments through outreach and scheduling.
• Advocates and facilitates referrals to gain access to services and resources for patients, including patient assistance programs, community-based services and mental health support.
• Assists with the coordination of care across the care continuum and transitions of care (including home care, outpatient care, ER care, and hospital care) while maintaining strict patient confidentiality.
• Advocates to help those who frequently access inappropriate levels of care.

Work requires walking, standing, sitting, lifting, reaching, bending and stooping. Must lift a minimum of thirty-five pounds shoulder high. Ability to travel/ drive between various locations is required for this position. Requires frequent verbal and written communication in English. Must have intact sense of sight, hearing and finger dexterity. Occasional intermittent noise and exposure to conditions such as dust, fumes and chemicals.

Education, Experience and Certifications

A High School Diploma or GED is required. Must possess excellent verbal and written communication skills. Must possess basic computer knowledge and ability to use Microsoft office applications. Strong organizational skills. Must have effective interpersonal skills. Must be able to respond quickly to changes in community and clinic settings.