65%

Work with Clients

• Assist patients in the community—through home visits, attending medical appointments, and accessing other community-based resources.
• Review referral forms, assessment screeners, or Electronic Medical Determine appropriateness for project participation in conjunction with the Project Coordinator. For patients not appropriate for the project, provide active referrals to other community resources.
• For clients who qualify for program, complete enrollment forms and other needed documentation and document in approved format in a timely manner.
• Complete all telephone and face-to-face contact with patients in a timely and professional manner.
• Complete client-centered treatment goals in collaboration with patients and review progress in meeting goals routinely and at identified 60-day check-in times.
• Assist patients in scheduling medical and social service appointments and attend appointments as needed or requested.
• Provided assistance with medical and behavioral health referrals to ensure client access and follow-through.
• Ensure the client’s access to interpreters and translators for medical and social service appointments.
• Assist patients in securing transportation to medical and social service appointments.
• Assist patients in obtaining necessary medications through patient assistance programs and other reduced-cost programs.
• Assist clients in accessing and understanding necessary health and wellness information provided by their medical provider and clinic.
• Provide support and education to patients to assist them in adhering to medical recommendations and taking medications as prescribed.

20%

Communicate and collaborate with internal staff and community partners

• Be onsite at the assigned clinic, community-based agency, or hospital system and build relationships with site staff.
• Provide regular and timely updates to medical providers, referral sources, and assigned clinics with respect to individual patients' progress to meet treatment goals and troubleshoot any problems or concerns.
• Complete all required documentation and data tracking in a detailed and timely manner and share reports per protocol
• Attend and actively participate in all project-related trainings and project meetings.

15%

Perform clerical duties, assist with tasks, and perform additional support functions as needed

• Assist with community data gathering, & needs assessments
• Adapt/create/assist with producing and sharing health education materials as applicable
• Assist with emergency situations and routine operations as needed