Contacts patients post discharge per QIP-NJ contractual requirements.
• Communicates with patient Care Team members (physicians, behavioral health team and/or other health care providers) to provide patient with integrative care.
• Carries out tasks to execute the medical and support service plans including but not limited to guiding patients to appointments and accompanying them when necessary.
• Acts as the primary liaison with medical providers to ensure patient adherence to care.
• Tracks patient attendance for medical appointments, initiates outreach as well as adhering to missed appointment procedures.
• Coordinates treatment plan adherence.
• Coordinates deliverables per HORIZON ISC program.
• Monitors internal data dashboard to coordinate patient care.
• Identifies community resources to address patients' social determinants of health.
• Provides referrals to community resources as needed and follows up to ensure referral completion.
• Maintains program database of community partners and referrals.
• Maintains documentation of all patient encounters and completes reporting requirements according to organizational and contractual requirements.
• Maintains strict confidentiality in accordance with state and agency policies.
• Attends and represents the organization at professional conferences, in-service training,
and meetings at the request of or with the approval of supervisor.
• Flexibility with covering weekend/evening shifts.
• Other duties as assigned.

Position Qualifications
• Excellent communication and interpersonal skills
• Experience working with behavioral health and/or substance use population.
• Experience working in a medical or social services environment preferred
• Strong attention to detail
• Proficient with computer databases
• Analytical problem-solving skills
• Ability to manage time, prioritize, and meet deadlines
• Ability to work independently and as a team member
• Good attitude, professionalism, promote team attitude
• Proficiency in Spanish preferred

Education
• Bachelors Degree in behavioral health field required
• Masters Degree in behavioral health field preferred
• Professional Licensure preferred