Full Job Description
Serves as a member of the interdisciplinary care management team to provide short term care coordination and connection to resources and programs for patients to improve their health and general well-being through education and provision of coordination of care and services. Works in both clinical and community-based settings, including patient’s homes. Serves as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery. Builds individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support, navigation support and advocacy. Community outreach, such as home visits,assessments, care coordination and health screenings required.
High school diploma or equivalent. Residency within the target population preferred.
Participation with a community organization, verified by personal or professional reference with personal knowledge of this fact, preferred.
No special certification, registration or licensure required.
Knowledge, Skills & Abilities
Effective oral and written communication skills. Personal knowledge of the target population, as shown by residency in that neighborhood. Cultural competency. Knowledge of local resources and system navigation. Advocacy Primary and community capacity building skills. Care coordination skills. Teaching skills to promote healthy behavior change. Outreach methods and strategies. Ability to bridge needs and identify resources. Understanding of ethics and confidentiality issues. Ability to use and understand health information technology.
Primary Duties and Responsibilities
Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards, and safety standards. Complies with governmental and accreditation regulations.
Advocates for individual and community health equity.
Assists patients 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.
Assists patients in their homes, community, or clinic setting. Communicates to patients the purposes of the program and the impact it may have on their wellbeing. Helps patients identify socio-economic issues that affect their overall health and develop health/social management plans and goals.
Collects, tracks and reports information about the community and community benefits.
Documents all patient encounters; completes and submits monthly reports; maintains comprehensive electronic client files, which include client notes, release of information, assessments and other medical documents acquired on behalf of the patient. Documents activities, service plans, and outcomes achieved by patient in an effective manner.
Educates client on the proper use of the Emergency Room/Health system services, and provides information for alternatives. Coaches patients in effective management of their chronic health conditions and self-care. Assists patient in understanding care plans and instructions. Motivates patients/clients to be active and engaged participants in their health and overall wellbeing.
Enhances community residents’ ability to effectively communicate with health care providers.
Identifies and addresses issues that create barriers to care for specific individuals.
Integrates with patients care team to support progress in care plan and overall patient wellness.
Proactively identifies and refers individuals to federal, state, private or nonprofit health and human services programs.
Provides care, support, follow up, and education in community settings.
Provides culturally and linguistically appropriate health education.
Provides evidence-based health guidance and social assistance to community residents.
Provides referral and follow-up services or otherwise coordinates human services options.
Serves as a liaison between communities, individuals and coordinated health care organizations.
Staffs community events and activities as needed.
Participates in meetings and on committees and represents the department and hospital in community outreach efforts. Participates in multi-disciplinary quality and service improvement teams.
Performs other duties as assigned.
About MedStar Health
MedStar Health is dedicated to providing the highest quality care for people in Maryland and the Washington, D.C., region, while advancing the practice of medicine through education, innovation and research. Our 30,000 associates and 5,400 affiliated physicians work in a variety of settings across our health system, including 10 hospitals and more than 300 community-based locations, the largest visiting nurse association in the region, and highly respected institutes dedicated to research and innovation. As the medical education and clinical partner of Georgetown University for more than 20 years, MedStar is dedicated not only to teaching the next generation of doctors, but also to the continuing education and professional development of our whole team. MedStar Health offers diverse opportunities for career advancement and personal fulfillment.