Job Description

1. Outreach and Community Engagement:

• Conduct outreach efforts to identify and engage community members in need of health services.
• Build and maintain relationships with community members, organizations, and local agencies.
• Organize and participate in community events, workshops, and health fairs to provide health education and resources.

2. Health Education:

• Provide culturally appropriate health information to improve health literacy and empower community members to make informed decisions.
• Develop and distribute educational materials to promote health and diagnosis awareness.
• Educate and assist with Living Wills, Durable Power of Attorney for Healthcare, Power of Attorney, Guardianship resources, and Advance Directives.
• Serve as a Notary Public as applicable.

3. Advocacy and Support:

• Assist individuals in navigating the healthcare system by providing information on available resources, services, and eligibility for programs.
• Accompany clients to medical appointments when necessary and act as a liaison between the client and healthcare providers.
• Advocate for the needs and rights of the community in accessing healthcare and social services.

4. Care Coordination and Referral Services:

• Discharge planning, including Coordinate referrals to Home Health, Hospice, Skilled Nursing Facilities, Assisted Living, Private Duty Care, Meals on Wheels, Lifeline, transportation services, waiver programs, and community resources.
• Conduct visits, phone calls, and follow-up sessions to ensure individuals receive necessary healthcare services.
• Collaborate with healthcare professionals, social workers, and other service providers to coordinate care.
• Maintain knowledge of and refer clients to appropriate health, social, and community resources, such as housing, nutrition assistance, and mental health services.

5. Financial and Insurance Assistance

• Assist with Medicaid applications and track status.
• Complete Presumptive Medicaid eligibility and maintain certification.
• Assist with Medicaid Waiver applications.
• Provide education regarding disability benefits, SNAP, insurance concerns, and financial assistance resources.

6. Data Collection and Reporting:

• Maintain accurate and up-to-date records of client interactions, services provided, and outcomes achieved.
• Collect and report data on community health needs, barriers to care, and other relevant metrics.
• Participate in regular team meetings and report on community trends and challenges.
• Participate in quality improvement initiatives, audits, committees, policy development, and continuing education.
• Active participation in Cancer Committee and Tumor Board.

7. Performs other duties as assigned.