Initiates telephonic or face to face contact with eligible patients to describe role, explain program benefits and begin assessment process.
Assists with connecting patients to mental health and recovery resources within their community.
Escorts patients to different programs within the hospital and community to connect with recovery resources.
Works with patient and provider to set goals for patient's care and motivates patients to achieve those goals.
Teaches key educational messages in person and over the phone. Clearly documents all activities in the patient's record.
Records and monitors the participants' progress toward goals within specific timeframes.
Participates with other staff in activities to program participants, including community outreach, presentations to community organizations, development of materials, and phone calls.
Assists patients with organizing their records, making follow-up appointments, and filling their prescriptions.
Helps patients fill out applications as needed.
Provides advocacy, patient education and support in accessing community-based and hospital-based programs.
Refers to internal or external care management services when other issues are identified (i.e. food insecurity, partner violence, etc.).
Demonstrates sensitivity and respect for the culture of the patient.
Participates in regular training activities.
Attends regularly scheduled supervision and other program assigned meetings.
Influences inappropriate utilization of health care resources by providing intensive home and community-based outreach, motivational interviewing and goal setting, resource connection and accompaniment to medical appointments as needed.
Presents patients at case review meetings succinctly and logically. Consults with experts regarding complex patient situations, demonstrating an understanding of how to solicit and incorporate provider feedback in order to continuously develop the most optimal plan for care.
Prepares reports and documents as needed or requested.
Demonstrates the ability to function within an inter-disciplinary team (nurse care coordinators, social workers, behavioral health clinicians, physicians, resource specialists, clinical support staff, etc.), connecting the patient with resources as needed.
Support the Operations Manager in the implementation and evaluation of quality initiatives.
May visit patients in hospital and ER and facilitate with transitions of care.
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 notice from the Department of Labor.
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