PRINCIPAL DUTIES AND RESPONSIBILITIES

• Patient Support Responsibilities are done both in-person and by phone
  1. Attend to patients through warm handoffs from the clinic.
  2. Screen patients for needs around social determinants of health and connect to internal and external resources.
  3. Provide linkage to services such as emergency financial assistance, transportation, food assistance, etc.
  4. Enroll patients in services, benefits, and programs for which they are eligible (pharmaceutical programs, LINK, financial applications for hospital referrals, early intervention support, DME, urgent referrals etc.).
  5. Assist patients in digital navigation, including MyChart enrollment, setting up telehealth capabilities, and other digital assistance related to health.
  6. Educate and empower patient to navigate future SDOH needs.
  7. Take on short-term agency initiatives related to SDOH, as they arise.

• Administrative Responsibilities
  1. Complete data entry for SDOH program.
  2. Distribute and track SDOH resources. This may include patient mailing of SDOH resources, Top Box Foods distribution, ordering Uber Health rides, and distributing other material resources.
  3. Use Epic to create SDOH panels and outreach lists.
  4. Use Epic to document work, create SDOH panels and outreach lists, respond to SDOH referrals, and communicate with clinical care teams.

• Other Responsibilities
  1. Build effective relationships with local social service agencies and advocate for clients in the process.
  2. Attend funder and partner meetings, trainings, conferences as directed.
  3. Attend all required internal meetings.
  4. Participate in internal and external committees, as directed.
  5. Promote positive image of Erie Family Health Center with community partners.
  6. Collaborate with healthcare providers (such as primary care provider, mental health provider, nurses, and case managers) to ensure high quality care for Erie patients.
  7. Perform other duties as assigned.