Overview: Coordinate services and collect data for the Team-Based Care program. Track participant progress, facilitate service connections, and collaborate with a multidisciplinary team. Support Field Directors and staff in implementing the program and tracking outcomes.

Locations: Hiring in multiple districts within Vermont - Bennington, Rutland, Brattleboro, Springfield/WRJ, Barre, STJ/Newport, St. Albans/Lamoille, Burlington, Middlebury.

Responsibilities:

• Understand team-based care requirements and function as a program team member.
• Collect and analyze data, prepare reports, and provide recommendations.
• Contribute to quality improvement and care redesign efforts.
• Review patient data and consult with care team for accurate service provision.
• Manage reports and provide necessary data to healthcare teams.
• Support Field Directors and providers in managing target populations.
• Proactively reach out to participants and assist with appointments.
• Support data management, coordination, and patient outreach.
• Ensure positive patient experience through effective communication.
• Synthesize and present data to care plan providers.
• Assist in process mapping and workflow development.
• Attend meetings and collaborate with the healthcare team.
• Adhere to policies and regulations, including HIPAA.
• Report policy infractions and escalate issues as needed.
• Perform light physical tasks and other assigned duties.

Basic Knowledge:

• Proficiency in Microsoft Office and electronic health records.
• Knowledge of process improvement methodologies.
• Strong understanding of databases and data communication.
• Excellent organizational and communication skills.
• Experience with Motivational Interviewing and complex health needs.
• Ability to collaborate with providers from different domains.

Minimum Requirements/Experience:

• Bachelor’s degree in a human services field or Community Health Worker certification.
• Minimum three years of experience in human services.
• Experience with electronic health records is desirable.

IND123