Responsible for the development of care plans for all clients referred to the program and linkage to the appropriate supportive services and for providing overall support to clients experiencing significant barriers to access and retention in care. Help clients in utilizing resources, including scheduling appointments, and assisting with completion of applications for programs for which they may be eligible. Ability to build and maintain positive working relationships with the clients, providers, nurse case managers, agency representatives, supervisors and office staff.
Scope of Duties:
- Complete Care Plans on all assigned clients based on approved agency assessment tools with client input.
- Assist clients with understanding care plans and instructions and motivate clients to be active, engaged participants in their health.
- Assist clients with scheduling medical appointments and follow up with providers to ensure client attendance.
- Assist clients with scheduling transportation to appointments and accompany clients to appointments as needed.
- Continuously expand knowledge and understanding of community resources, services and programs provided; human relations and the procedures used in dealing with the public as part of a service or program; volunteer resources and the practices associated with using volunteers, operations, functions, policies and procedures associated with the department or program area, procedures and resources available to handle new, unusual or different situations.
- Facilitate health education to assist clients with disease management and schedule on site workshops with community resources.
- Build and maintain positive working relationships with the clients, providers, nurse case managers, agency representatives, supervisors and office staff.
- Help clients in utilizing resources, including scheduling appointments, and assisting with completion of applications for programs for which they may be eligible.
- Assist 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 social services.
- Assists in the collection of outcome data.
- Maintain timely, accurate and clear documentation in accordance to agency requirements.
- Attend and participate in team meetings, communicate with county and community based agencies/professionals; patient care coordination and navigation.
- Interact (verbally and non-verbally) with all clients, staff, and community members professionally with respect and courtesy.
- Maintain client and staff confidentiality in compliance with administrative policies and procedures.
- Attend and participate in regularly scheduled staff meetings, supervisory conferences and training sessions.
- Other duties as assigned.
ADA Essential Functions:
- Regularly required to stand and walk
- Occasionally lift and move up to 25 lbs.
- Ability to observe an area that can be seen up and down or to the left and right while eyes remain fixed on a given point.
- Possible exposure to infectious organisms through contact with community members.
- Exposure to agitated patients and family members.
- Ability to read standard text and data on a computer terminal.
- Ability to hear conversations in a noisy environment.
- Ability to communicate verbally in person and over the telephone.
- Ability to physically assist ill patients and/or push a patient in a wheelchair.
Preferred
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Bachelors degree in one of the helping professions with three years experience in the healthcare/social services field. Knowledge of local population demographics, needs, and health disparities such as diabetes and hypertension. Must have the ability to connect the person’s served with community supports as well ongoing support in a behavior change process. Must demonstrate organizational and time management skills.
- Thorough working knowledge of social learning theory, cognitive-behavioral intervention and approaches, assessment and evaluation required. Ability to effectively communicate verbally and in writing in order to document client information and progress in the required systems. Must demonstrate competencies in training, group interaction, mentoring and following directive. Must possess a valid driver's license and be able to meet agency standards.
Required
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Bachelors or better in Human Services or related field
Required
Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities
This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights (https://www.eeoc.gov/poster) notice from the Department of Labor.
