Job Description

Basic Function: Responsible for helping patients and their families to navigate and access community services, resources, and adopt healthy behaviors. Activities will promote, maintain, and improve the health of patients and their family.

Principal Accountabilities:

1. Responsible for establishing trusting relationships with patients and their families while providing general support and encouragement
2. Provide ongoing follow-up, basic motivational interviewing and goal setting with patients/families
3. Follow-up with patients via phone calls
4. Review social determinants of health screenings for patients and work to connect patient with community services to address needs
5. Help patients connect with transportation resources and provide appointment reminders in special circumstances
6. Work collaboratively with other clinical personnel assigned to the same patient
7. Knowledgeable about community resources appropriate to needs of patients/families
8. Act as a patient advocate and liaison between the patient/family and community service agencies
9. Record patient care management information in the EMR
10. Manage assigned caseload of patients
11. Comply with all OSHA regulations, NYSDOH, Quality & organization policies and procedures.
12. Engage in Patient Centered Medical Home initiatives
13. Other duties and responsibilities as requested by management and/or supervisor.

Requirements

Knowledge/ Education Requirements:

A. Associates degree in related field preferred, high school graduate or equivalent required

B. Prior experience in a related field preferred

C. Must demonstrate computer proficiency with Microsoft Suite and electronic medical record system

D. Must possess a willingness to accept direction from providers and supervisors

E. Must possess the ability to work well and with compassion in stressful situations

F. Must maintain a professional and courteous demeanor with both patients and coworkers

G. Must be keenly aware of the importance of confidentiality in all aspects of the position