What You Will Do:

I. General Summary
Under general supervision, visits individuals and families in their homes, in shelters or other similar places to provide basic community outreach services and to assist with programmatic interventions necessary in coping with the transition from hospital to community, or reducing the risk of being admitted to the hospital.

II. Principal Responsibilities and Tasks
The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all job duties performed by personnel so classified.

• 
  1. Participates as a member of the UMSJMC C.A.R.E.TM program to ensure clients’ needs, and access to resources monitoring according to the client’s care plan.
• Establishes a relationship with clients and their families to provide general support and encouragement by making telephone contact and conducting home visits.
• Conducts intake interviews with clients and completes the Social Determinants of Health (SDOH) assessment. Determines clients’ needs, health patterns, coping skills and identifies priorities for community-based care management in conjunction with the care plan established by the UMSJMC C.A.R.E.TM team.
• Assists clients in addressing challenges to care such as transportation, insurance, housing, food, and other community resources according to primary care providers, specialists, transitional care and UMSJMC C.A.R.E.TM recommendations.
• Performs and documents vital signs in consultation with the RN. This may include: blood pressure, weight checks, pulse and respiration. May assist in setting up telehealth monitoring devices for participants.
• Schedules appointments and performs reminders (via telephone calls, home visits and visits to other community-based organizations, as appropriate) to ensure appropriate resources are available to attend appointments.
• Communicates regularly with the clinical team, primary care provider, and community-providers (as appropriate) on client needs, concerns, treatment adherence, interests and any changes to ensure seamless continuity of care.
• Serves as a liaison between the UMSJMC C.A.R.E.TM and community providers.
• Documents clients’ needs, care plans and follow-up actions in the CRISP/care management platform.
• Supports and reinforces clients on self-care, healthful living and setting/achieving goals.
• Adheres to HIPAA confidentiality rules and regulations.
• Demonstrates critical thinking skills in identifying any significant changes in the clients’ situation.

What You Need to Be Successful:

• High School Diploma or equivalent is required, Associate’s degree preferred.
• Outreach experience in a health care environment, medical practice or community-based setting such as social services, supportive services, personal care or related duties working with the adult or senior populations, is preferred
• BLS, required.
• Phlebotomy or Medical Assistant certification OR prior phlebotomy experience (one year), preferred.
• Basic computer skills, required.

We are an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, disability, protected veteran status, age, or any other characteristic protected by law.