QUALIFICATION REQUIREMENTS:

• Must have a Valid Driver’s License.
• Must have reliable transportation and proof of automobile insurance.
• Current CPR certification is required.
• Ability to report to work as scheduled and work a flexible schedule when necessary.
• Ability to pass a drug screen and background check.

SKILL AND KNOWLEDGE REQUIREMENTS:

• Excellent analytical, problem-solving, and prioritization skills.
• Use statistical and graphic displays.
• Excellent verbal and written communication skills.
• High-level interpersonal skills. Able to work collaboratively and tactfully with multi-disciplinary and diverse teams that may include employees, customers, and physicians.
• Effective computer skills, particularly Microsoft Office, Excel, PowerPoint, Publisher, Paint, Word, etc.
• Work independently to complete assigned tasks.
• Team building
• Project Management
• Change Management
• Quality and Process improvement tools
• Project Execution

1. Assists clients in their homes, community, or clinic setting.
2. Travels extensively to client homes, community locations, various agencies, and other outreach destinations.
3. Communicates to clients/patients the purposes of the program and the impact it may have on their wellbeing.
4. Helps patients identify socio-economic issues that affect their overall health and develop health/social management plans and goals.
5. Educates client on the proper use of the Emergency Room and provides information for alternatives.
6. Coaches patients in effective management of their chronic health conditions and self-care. Assists patient in understanding care plans and instructions.
7. Motivates patients/clients to be active and engaged participants in their health and overall wellbeing.
8. Assists clients in accessing health related services, including but not limited to: obtaining a medical home, providing instruction on appropriate use of the medical home, overcoming barriers to obtaining needed medical care and /or social services.
9. Provides support and advocacy during initial medical visit or when necessary to assure clients’ medical needs and referrals required are being conveyed.
10. Follows up with both clients and providers regarding health/social services plans.
11. Facilitates communication and coordinate services between providers and the clients/patients. Coordinates and monitors services, including comprehensive tracking of clients’ compliance in relation to care plan objectives.
12. Documents all client encounters and contracts made on behalf of clients; completes and submits monthly reports;
13. Maintains comprehensive electronic client files, which include client notes, release of information, assessments and other medical documents acquired on behalf of the client. Documents activities, service plans, and outcomes achieved by client in an effective manner.