Job Description

This role assists primary care providers, nurses, and care managers with identifying and resolving member Social Determinants of Health (SDOH) and non-clinical healthcare care needs of members. Skills that are key to the success of this position include building trusting relationships focused on meeting member goals, maintaining knowledge of community resources, understanding eligibility requirements and application processes for benefits and resources (e.g., health plan benefits, entitlements, SNAP, housing/shelter programs, transportation), identifying the appropriate resource for each member’s unique situation, and organizational skills to follow up timely to ensure successful access to resources. This role includes working in the Medical Center with members, as well as working outside of the Medical Center (member’s homes, community organizations, external providers, etc.) to support members in achieving their care needs.

Duties and Responsibilities

• Receive referrals from the Integrated Care Team (ICT) to address members’ SDOH needs as identified during routine assessment or as requested by the member.
• Work with members in the center, in the community, and telephonically to engage, build relationships, and connect to SDOH resources.
• Support members in adhering to their care plan with peer-to-peer support, including but not limited to:
• Medical Advocacy: Member needs someone to accompany them to community referrals/appts, needs support in home when medical equipment is delivered, (i.e., Low health literacy and requires assistance at appts)
• Transportation: Supporting member in accessing transportation to and from appointments.
• Care plan adherence: Contacting and locating members who miss appointments with their providers or follow up after hospitalization, removing barriers to accessing prescriptions (coordinating or completing delivery)
• Housing: Member requires assistance in review of potential housing options -- viewing new settings for potential risks/barriers to member health, e.g., stairs, proximity to public transportation, food access, safety
• Supporting members in accessing our services associated with care pathways (ie – SMI, CKD).
• Assist members with referrals and coordinating services with community resources including, but not limited to:
• Housing, e.g., voucher programs, halfway houses, shelters
• Government benefits, e.g., SNAP, phones, transportation
• Food and personal/household items e.g., food pantries, soup kitchens, homeless outreach centers, clothing, seasonal resources such as toy and backpack drives, winter clothing closets
• Utility assistance, e.g., LIHEAP
• Advocacy including coordinating letters of medical necessity related to eviction or utility shut off notices
• Obtaining picture ID and/or birth certificate documents
• Medication assistance, i.e., enrolling patients in any assistance available for medication co-pays
• Transportation, e.g., health plan eligibility, public transportation / bus passes
• Educational and vocational resources

• Coordinate with relevant ICT members to collect all necessary documents required to connect members to resources (provider referral, documentation of diagnosis etc.)

• Work closely with the Behavioral Health team related to mental health and substance use services and referrals (SMI Pathway)
• Follow primary care provider action plan assigned tasks to meet member needs.
• Communicate with assigned care managers and interdisciplinary care team to provide status of barriers, interventions, and referrals to facilitate continuity of care, including participating in integrated care team huddles, population health meetings, and ad-hoc case consultations.
• Document all interactions with the member and/or on behalf of the member in the electronic health record following required timeliness standards of documentation.
• Prioritize tasks to ensure requests are completed in a timely manner by appropriately discerning the urgency of the need and meeting response time performance metrics.
• Work within a team and attend daily huddles at the start of the day to plan out member interactions and follow up.

Minimum Qualifications

• High school diploma or equivalent required.
• Must have a valid driver’s license, proof of insurance, and reliable personal vehicle.
• 2+ years of experience working with community agency providing services encompassing the basic competency areas of health care (community resources, communication skills, individual and family advocacy, health education, services skills, and responsibilities).
• Certified as a Community Health Worker preferred
• Experience and passion for working with and engaging vulnerable, hard to engage, complex populations.
• Independent and persistent self-starter
• Proficient in PC skills, such as Microsoft Office.
• Ability to travel locally up to 80% of the time.
• Knowledge and trusting relationships within local community, and experience and knowledge navigating community resources.

Working conditions

This job operates in a professional office environment and out in the local community. This role routinely uses general office equipment. This role requires access and use of own reliable transportation, current driver’s license, and proof of insurance to complete visits out in the community.

Physical requirements

• Driving and walking in the community where our members live.
• Ability to communicate clearly and exchange accurate information constantly.
• Ability to remain stationary for long periods of time.
• Ability to operate computer, keyboard, copy and fax machine, phone, and other general office equipment.
• Ability to occasionally move objects up to 20 lbs.

Direct reports

None.

All Employees are expected to maintain the security and privacy of all information that is owned by AbsoluteCare or maintained on behalf of the company’s patients, employees, and business partners. Nothing in this job description restricts management’s right to assign or reassign duties and responsibilities to this job at any time. This description reflects management’s assignment of essential functions, it does not proscribe or restrict the tasks that may be assigned. This job description is subject to change at any time.