Responsible for supporting the care management team goals by helping individuals access and obtain community resources, adopt healthy behaviors through education, and assist with navigation throughout the healthcare system. This position networks with and connects
individuals to home and community based services, frequently meeting individuals and their supports in the community.

General Functions:

• Assist clients in overcoming barriers and obtaining resources to support the social, medical,
• and individual-centered action plan.
• Responsible for client follow up, as assigned by licensed colleague.
• Work closely with individuals under the direction of the licensed team in collaboration with
• the Care Manager to ensure adherence to medical visits. Helps individuals access and
• utilize available resources to address a variety of needs including social determinants of
• health by assisting with referrals, completing financial and other applications, as applicable.
• According to the care plan, follow-up with clients via home visits or phone calls as necessary
• to monitor progress to goals.
• Able to adhere to productivity standards for call volume and visit volume per communicated
• policy.
• Able to adhere to quality standards for care management per policy, including documentation.
• Document activities, goals, and outcomes in a timely manner following prescribed
• documentation policies and procedures.
• Be responsible for providing consistent and regular communication to the individuals of the
• Care Management Team for ongoing evaluation of the individual/family status.
• Help motivate clients to be active and engaged participants in their health through active follow-up in accordance with initiated plan of care initiated by licensed team member.
• Build and maintain positive working relationships with clients, providers, and the care
  management team.
• Continuously expand knowledge & understanding of community resources.
• Utilize resources efficiently and effectively.
• Must be proficient in various word processing, spreadsheet, graphics, and database
  programs, including Microsoft Word, Excel, PowerPoint, Outlook, etc.
• Other duties as assigned.

Minimum Education:

• Bachelors in Health Services or a Community Health Worker Certification.
• Clinical experience in nursing preferred in addition to above requirement.

Required:

• Must have own reliable transportation.
• Knowledge, Skills & Abilities:
• Requires excellent interpersonal and customer service skills, strong ability to educate,
• and excellent communication skills both written and verbal.
• Requires basic computer skills.
• Requires ability to drive an automobile safely.