JOB SUMMARY:

Provides a range of client-centered services that link clients with health care, psychosocial support, and other services. Provide support services to assist patients in overcoming barriers, which will enable them to have timely access to quality healthcare. Assists with scheduling patients for their AWV with their primary care provider, along with any preventive screening needed. Will link community members to the resources they need such as: health screening information, healthcare providers, assistance with publicly funded health insurance and grant funded programs. This position enhances the quality of the Care Coordination team’s ability to provide proactive patient management, increased patient and provider satisfaction, and continuity of patient care.

DUTIES AND RESPONSIBILITIES:

1. Provides outreach to individuals in a variety of settings including but not limited to in the clinical setting, health fairs, clinic outreach, and patient lists for targeted outreach.

2. Deliver culturally appropriate and accessible health education and information.

3. Help clients in utilizing resources, including scheduling appointments, and assisting with completion of applications for programs for which they may be eligible.

4. Navigate through healthcare system (e.g. by providing assistance with enrollment, appointments, scheduling referrals, transportation, promoting continuity of health services providing for bilingual services and translation .

5. Works with care coordination team, assisting with scheduling AWV and preventive screenings

6. Identifies and recruits potential candidates for the ABCCEDP and the WISE WOMAN program

7. Tracks OB patients throughout pregnancy, including birth and the postpartum period documents place of birth, birth date, birth weight, , and birth location

8. Assists care team by tracking and supporting patients when they obtain services outside the practice. Closing the referral loop as needed

9. Works with the provider care teams by utilizing internal and external data sources, identifies and contacts patients identified through various practice protocols and initiatives.

10. Educates patients and families to assist them to make informed personal health care decisions.

11. Assists in the implementation and ongoing evaluation of patient self-management goals.

12. Understands and follows policies and procedures and produces and submits reports in a timely manner.

13. Collaborate with clinical staff and social workers as needed in the development and execution of the plan of care, and achievement of goals.

14. Serves as a patient advocate. Acts as a liaison between the patient care team, healthcare facility, and community agencies among all Franklin Primary Health Center clinics.

15. Other related duties as assigned.

QUALIFICATIONS:

EDUCATION AND EXPERIENCE:

Graduate of an approved CHW Program or an equivalent combination of experience, education or training that provides the level of knowledge, skills and ability required with two years of directly related experience coordinating patient programs. Direct related experience may be substituted on a year-to-year basis for the required education.

Knowledge, Skills and Abilities:

Knowledge of care coordination services. Knowledge of organizational policies, regulations and procedures to evaluate and administer patient care plans. Skills in establishing and maintaining effective working relationships with patients, medical staff, and the public are required. Skills are required in preparing and maintaining records, writing reports, and responding to correspondence via e-mail. Proficient in the Microsoft Office Suite required. Excellent organizational skills and ability to multi-task required. Strong written and oral communication skills required. Ability to interpret, adapts, and apply guidelines and procedures. Ability to work independently, learn new skills and self-direct learning to accomplish tasks. Ability to cooperate; works well with others in a multi-disciplinary team setting. Professional appearance and professional conduct at all times.

Job Type: Full-time

Pay: $17.50 - $22.00 per hour

Benefits:

• 403(b) matching
• Dental insurance
• Health insurance
• Life insurance
• Loan forgiveness
• Paid time off
• Parental leave
• Retirement plan
• Vision insurance

Schedule:

• 8 hour shift

Work Location: In person