Overview

Provides education, member advocacy, accompaniment to medical care appointments as determined by team leaders. Participates in team meetings to discuss regular evaluation and feedback about clients on caseload. Works with client to determine their eligibility for other social service programs and identify barriers to regular medical care and follow-up. Alerts team members when supportive social & community services required and ensures efficient and successful access and linkage to the full array of edu and health plan services. Contributes to the goal of client's engagement in medical care as prescribed by their medical care team. Works under close supervision.

Compensation Range:$17.49 - $21.80 Hourly

What We Provide

• Referral bonus opportunities

• Generous paid time off (PTO), starting at 20 days of paid time off and 9 company holidays  

• Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life and Disability   

• Employer-matched retirement saving funds  

• Personal and financial wellness programs   

• Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care    

• Generous tuition reimbursement for qualifying degrees  

• Opportunities for professional growth and career advancement   

• Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities    

• Interdisciplinary network of colleagues through the VNS Health Social Services Community of Professionals.

What You Will Do

• Reviews rosters with supervisor to identify members that require follow up and assistance.

• Notifies and assists of any immediate needs and risk factors and makes referrals to services to address such needs.

• Coaches members by providing motivational interviewing techniques and skills to address medical and psycho-social health. Motivates and supports client to participate in their individualized care plan, including home visits and accompaniment to medical appointments as determined by team leaders.

• Provides outreach via phone and face to face to clients for a follow up on self-care, medication fills/refills, adherence scheduled visits, and test results received from providers.

• Reinforces education provided by members medical providers related to the management of the chronic disease or conditions identified; helps educate clients about conditions, risk of poor follow up in medical care and self care/condition management.

• Works closely with the outreach team to discuss clients’ progress, personal and systemic barriers and issues of health equity. Participates in design of follow up plans and strategies for outreach and engagement of members.

• Assists with client navigation of health system, including accompaniment & advocacy with issues of access, appointments and other member needs.

• Prepares detailed, accurate and timely case notes and utilizes in house platform as required to note client progress and updates and relevant information.

• Works collaboratively with team members to provide outreach for and engage hard to reach or lost to follow up members with overdue screenings or upcoming appointments and /or who have missed treatment appointments.

For Select Health:

• Assists outreaching by phone and face to face visits members who have been hard to reach for the care management team or their medical providers. Provides canvasing efforts to locate client.

• Assists clients in obtaining medical appointment. Accompany to appointments as determined by team leaders.

• Uses motivational interviewing techniques and skills to identify systemic and personal & social barriers to engagement in care.

• Provides guidance on self-management tools, assists in health literacy.

• Facilitates periodic case record reviews and case conferences with all providers serving the client.

For CMO:

• Assists with general program support in areas of technology such as CarePort, Interactive Voice Response (IVR) Remote Patient Monitoring and Tiger Text.

For Wellness Program:

• Reviews new cases for completeness of documentation.

• Participates in special projects and performs other duties as assigned.

Qualifications

Licenses and Certifications:

• Peer navigation or CHOW training preferred

Education:

• High School Diploma or equivalent required

• Associate's Degree In human services or related field or equivalent experience preferred

Work Experience:

• Minimum of one year experience in care management, community health, social service, or medical practice preferred

• Experience in working with underserved and under resourced communities including communities of color required

• Lived experience preferred

• Experience in working with individuals with substance use and mental health issues preferred

• Experience in working with members of the LGBT community preferred

• Basic computer skills required

• Empathetic, non-judgmental communication style required

• Effective oral/written/interpersonal communication skills required

• Bilingual skills as determined by operational needs preferred