EDUCATION & EXPERIENCE:

• High school diploma or equivalent required, college degree a plus. Associates degree or Bachelor’s degree preferred.
• One year of related experience working in programs with at risk populations and performing outreach is required.

KNOWLEDGE, SKILLS, ABILITIES AND OTHER (KSAO’S)

• Working knowledge of social determinants and impact on health outcomes is preferred
• Knowledge of regional community resources/services is important.
• Computer knowledge should include Microsoft Word and Excel.
• Bilingual (English-Spanish/English-Creole) preferred.
• Good communication, problem solving, team work and organizational skills are required in order to engage participants.
• Ability to work with multicultural and diverse population is required.
• Must be self-motivated, detail oriented, able to travel locally and work flexible hours.
• Must have a passion about working to improve the health and quality of life of the population.
• Demonstrates consistent effort to maintain sound working relationships with staff.
• Demonstrates flexibility and cooperation in relation to workplace manpower and staffing needs by rotating on an emergent basis and providing assistance, as needed.
• Consistently utilizes appropriate lines of authority, as needed.

PHYSICAL & WORK REQUIREMENTS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
This position requires the manual dexterity sufficient to operate phones, computers and other office equipment. The position requires the physical ability to kneel, bend, and perform light lifting. This person must have the ability to write and speak clearly using the English language to convey information and be able to hear at normal speaking levels both in person and over the telephone. Specific vision abilities required by this job include close vision, depth perception and the ability to adjust focus. Generally, the working conditions are good with little or no exposure to extremes in health, safety hazards and/or hazardous materials.
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Health Education and Care Coordination:

• Demonstrates health literacy of the field, assures treatment adherence education, and provides emotional support to clients.
• Educates and assists clients in knowing what materials to bring or questions to ask in order to facilitate access to needed services, such as obtaining and identification (ID) card for housing application, health insurance, or application for other social support services.
• Walks clients through initial appointments for medical care or other social services in order to ensure that clients have a clear understanding of initial steps that need to be taken to obtain appropriate services.
• Promotes effective resource utilization with the multidisciplinary team.
• Identify beneficial local resources and keeping track of patient’s referrals and assisting with keeping appointments.
• Promotes the program within HJAHC and other health care organizations that feed and draw from HJAHC.
• Participates in staff training sessions and other meetings as required by the agency

ESSENTIAL FUNCTIONS

Outreach and Health-Systems Navigation:

• Engages in case finding and community outreach to bring out-of-care patients/clients who have never accessed care, or those that are lost to follow up into care services.
• Establishes and maintains external contacts on a regular basis. Facilitates weekly/regular calls to check-in, for encouragement, appointment reminders, and to reschedule missed appointments.
• Accompanies clients to medical, mental health, substance abuse treatment or social service appointments in order to improve attendance and for affiliation support.
• Helps clients to schedule medical appointments and follows up with providers to ensure that clients attend appointments - coordinating and assisting with transportation.
• Helps plan and coordinate Chronic Care Management in conjunction with medical providers.

Health Education and Care Coordination:

• Demonstrates health literacy of the field, assures treatment adherence education, and provides emotional support to clients.
• Educates and assists clients in knowing what materials to bring or questions to ask in order to facilitate access to needed services, such as obtaining and identification (ID) card for housing application, health insurance, or application for other social support services.
• Walks clients through initial appointments for medical care or other social services in order to ensure that clients have a clear understanding of initial steps that need to be taken to obtain appropriate services.
• Promotes effective resource utilization with the multidisciplinary team.
• Identify beneficial local resources and keeping track of patient’s referrals and assisting with keeping appointments.
• Promotes the program within HJAHC and other health care organizations that feed and draw from HJAHC.
• Participates in staff training sessions and other meetings as required by the agency.

Documentation, Compliance and Quality Assurance:

• Assists in the collection of outcome data.
• Maintains timely, accurate, legible and clear chart documentation according to agency requirements.
• Maintains record keeping requirements and assists with chart reviews for Q/A purposes as requested.
• Works with data resources and health information products to drive productivity and quality improvement.

Safety:

• Follows universal precautions according to Centers for Disease Control and Prevention guidelines.
• Understands and appropriately acts upon assigned role in Emergency Code System
• Understands and performs assigned role in agency’s Continuity of Operations Plan (COOP).

ADDITIONAL RESPONSIBILITIES:

• Performs other duties and assumes other responsibilities as apparent and/or as assigned by [Reports to Position]. Duties, responsibilities and activities may change or new ones may be assigned at any time with or without notice.