Job Summary: 

• Establishes a direct and active collaboration among agencies and health institutions
• Coordinate and document the calendar of activities
• Work in the expansion of the network and participation of agencies/entities in the program
• Maintains updated community resources and agencies database
• Coordinate and conduct activities to increase awareness and use of public health
• Makes appropriate referrals to health clinics for people seeking services
• Support a referral system that facilitates the enrollment of community residents into clinical services at Alivio
• Act as liaison between participants and Alivio Services
• Prepare and submit activities reports, demographic data reports, and other required reports
• Conduct outreach activities throughout the community on topics related to health
• Assists with activities related to the Alivio Medical Center outreach events
• Coordinate and plan the implementation of health fairs and special community events
• Provide presentations on topics related to health 
• Participates in internal and community meetings

Skills on Resume:

• Collaboration (Soft Skills)
• Calendar Management (Hard Skills)
• Network Expansion (Soft Skills)
• Database Management (Hard Skills)
• Health Awareness Coordination (Hard Skills)
• Referral System Support (Hard Skills)
• Community Outreach (Soft Skills)
• Report Preparation (Hard Skills)

Job Summary: 

• Assist patients in identifying and navigating to and through various health and social resources that will help patients achieve better health outcomes
• Work as part of a collaborative care team to achieve optimal quality, cost, and patient experience outcomes
• Collaborate with patients, clinical staff across a variety of areas within Providence, and community partners to empower patients in securing the services and support they need in a longitudinal model of care
• Record activities in appropriate electronic records to fulfill requirements of measurement, coordination, payment, and documentation
• Outreach and follow-up to provide screening for eligibility, and one-on-one health insurance enrollment and application assistance
• Participate in regular meetings of Community Care Coordinators and the CHW Community of Practice
• Assess for social determinants of health in the community, primary care setting, and the Emergency Department and then refer them to the appropriate programs and resources in the community
• Works on special projects related to social determinants of health
• Plans, coordinates, and reports on health promotion and wellness education outreach activities for the UnitedHealthcare Community and State plan in Tennessee
• Develops relationships with community organizations and providers to close gaps and allow for warm handoffs of members requiring community resources
• Create a positive experience and relationship with the member
• Proactively engage the member to manage their care
• Help to keep members compliant with their care plans

Skills on Resume: 

• Patient Navigation (Soft Skills)
• Collaborative Care (Soft Skills)
• Electronic Documentation (Hard Skills)
• Health Insurance Assistance (Hard Skills)
• Social Determinants Assessment (Hard Skills)
• Health Promotion (Hard Skills)
• Community Outreach (Soft Skills)
• Relationship Building (Soft Skills)

Job Summary: 

• Assists in offering interpretation and translation services, provides culturally appropriate health education and information
• Assists people in receiving needed care, provides informal counseling and guidance on health behaviors
• Establishes trusting relationships with patients and their families while providing general support and encouragement
• Conducts intake interviews with patients, including enrolling and/or referring patients to local services
• Follows up with patients via phone calls, makes home visits, and frequents other settings where patients can be found
• Assists patients with completing applications and registration forms
• Conducts eligibility determination, enrollment and follow-up with uninsured patients
• Helps patients set personal goals and attend appointments
• Applies developing/basic working knowledge and experience to the job
• Helps patients connect with transportation resources
• Exhibits excellent working relations with patients, visitors and staff, effectively communicating the organization's mission
• Works on routine assignments within defined parameters, established guidelines, and precedents
• Works closely with medical provider/s to help ensure patients have comprehensive and coordinated care
• Follows patients from initial identification through closure

Skills on Resume: 

• Translation (Hard Skills)
• Health Education (Hard Skills)
• Patient Support (Soft Skills)
• Intake Interviews (Hard Skills)
• Follow-up & Home Visits (Soft Skills)
• Application Assistance (Hard Skills)
• Eligibility Determination (Hard Skills)
• Coordinated Care (Soft Skills)

Job Summary: 

• Convey the purposes and services of a program to the user population and the impact that program or service would have
• Help patients develop health management plans and goals
• Follow-up with health management/care plans with both patients and providers
• Coach patients in the effective management of their chronic health conditions and self-care
• Assist patient in understanding care plans and instructions
• Document activities, service plans, and results in an effective manner while strictly adhering to the policies and procedures in place
• Establish positive, supportive relationships with participants and provide feedback
• Help clients in utilizing resources, including scheduling appointments, and assisting with the completion of applications for programs for which they may be eligible
• Assist clients in accessing health-related services, including obtaining a medical home, providing instruction on the appropriate use of the medical home, overcoming barriers to obtaining needed medical care and social services
• Facilitate communication and coordinate services between providers
• Motivate patients to be active, engaged participants in their health
• Effectively work with people (staff, clients, doctors, agencies, etc) from diverse backgrounds in reducing cultural and socio-economic barriers between clients and institutions
• Build and maintain positive working relationships with the clients, providers, nurse case managers, agency representatives, supervisors, and office staff

Skills on Resume: 

• Program Communication (Soft Skills)
• Health Management Coaching (Soft Skills)
• Care Plan Follow-up (Soft Skills)
• Chronic Condition Coaching (Soft Skills)
• Documentation (Hard Skills)
• Resource Assistance (Soft Skills)
• Service Coordination (Soft Skills)
• Relationship Building (Soft Skills)

Job Summary: 

• Maintains an environment of safety for patients, self, and others.
• Actively participates in departmental, service line, and/or organization quality improvement initiatives to ensure patient, departmental, and organizational goals/outcomes are met or exceeded.
• Reports issues and system barriers for efficient and effective care plan support to the Population Health Manager and the Population Health Team Leads per policy.
• Interdisciplinary Care Planning, Resource Coordination, and Health Coaching.
• Appropriately identifies, provides, & documents the provision of potential community and health system resources to address barriers to care.
• Partners with the interdisciplinary care team to support the patient’s care plan to ensure barriers to care have been addressed and the patient is provided with appropriate resources and services.
• Actively participates in huddles, interdisciplinary care team meetings and other departmental meetings to address identified barriers so that patients can make progress toward care plan goals/outcomes on time.
• Communicates effectively through documentation in the electronic medical record and by verbal interactions with the physician, interdisciplinary care team, patient, and family/caregivers.
• Partner with care team (community, providers, internal staff) and may conduct member assessments
• Involved in data collection and reporting related to social needs of members
• Follows established procedures and receives daily instructions on work
• Provides consistent communication to management to evaluate patient/family status, ensuring provided information and reports clearly describe progress
• Attends regular staff meetings, trainings, and other meetings
• Work closely with community partners to engage, recruit, and train members of identified communities to reach the target population and achieve vaccination goals

Skills on Resume: 

• Safety Maintenance (Soft Skills)
• Quality Improvement (Soft Skills)
• Issue Reporting (Soft Skills)
• Care Planning (Soft Skills)
• Resource Coordination (Soft Skills)
• Communication (Soft Skills)
• Data Reporting (Hard Skills)
• Community Engagement (Soft Skills)

Job Summary: 

• Initiates telephonic or face-to-face contact with eligible patients to describe roles, explain program benefits and begin the assessment process.
• Schedules and completes initial home visit assessment, care plan, and follow-up home visits and phone calls for enrolled patients within specified timeframes.
• 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.
• Document all activities in the patient's record.
• Reinforces educational messages regarding disease self-management by linking clients with supportive community services and programs.
• Records and monitors the participants' progress toward goals within specific timeframes.
• Documents assessments and key patient updates in Epic system, documents relevant day-to-day activities and patient data.
• Participates with other staff in activities for 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.
• 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, domestic violence, etc.).
• Demonstrates sensitivity and respect for the culture of the patient, as well as participates in regular training activities.

Skills on Resume: 

• Patient Outreach (Soft Skills)
• Care Plan Development (Soft Skills)
• Goal Setting (Soft Skills)
• Patient Education (Soft Skills)
• Documentation (Hard Skills)
• Community Resource Referral (Soft Skills)
• Progress Monitoring (Soft Skills)
• Cultural Sensitivity (Soft Skills)

Job Summary: 

• Establish trusting relationships with, and act as a liaison for clients to access resources and agencies that assist the client to manage their health better.
• Screen residents for the Social Determinants of Health (SDOH) and then provide clients with the information needed to begin taking action to address those needs.
• Provide information to clients about the benefits of preventative care to help avoid and/or address health conditions including blood pressure and blood sugar monitoring.
• Motivate clients to be proactive about their health, while providing general support and encouragement.
• Provide follow-up appointments and referrals at community health screenings for clients in need of connection to a primary care physician or in need of follow-up for an abnormal screening.
• Assist with data collection and data entry for community screenings, community surveys, etc.
• Attend health fairs and other community events to provide information on effective disease prevention methods and share resources available in the Greater Bridgeport area.
• Assist with food collection and distribution done in partnership with the Health Improvement Alliance (HIA).
• Identify and apply appropriate role definitions and skilled boundaries
• 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 to continuously develop the most optimal plan for care.
• Prepares reports and documents and supports the Operations Manager in the implementation and evaluation of quality initiatives.
• 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

Skills on Resume: 

• Relationship Building (Soft Skills)
• SDOH Screening (Hard Skills)
• Preventative Care Education (Soft Skills)
• Patient Motivation (Soft Skills)
• Follow-up Coordination (Soft Skills)
• Data Collection & Entry (Hard Skills)
• Community Outreach (Soft Skills)
• Interdisciplinary Teamwork (Soft Skills)

Job Summary: 

• Follows established Upper Peninsula Health Plan (UPHP) policies and procedures, objectives, safety standards, and sensitivity to confidential information.
• Serves as a liaison between physical health, behavioral health, and service providers in communities
• Act as a key knowledge source for services and information needed by members for improved health and stability in their lives.
• Serves as a key knowledge source for community resources, UPHP health plan benefits, and other services.
• Builds individual and community capacity to identify and address barriers to health care and improve member quality of life.
• Conducts SDoH screenings and HRAs
• Engages members in care coordination through various outreach activities and arranges services to meet social needs including housing, utility, food, transportation assistance, and surrounding support services.
• Collaborates with UPHP care management staff and refers members with ongoing complex needs for care management.
• Provides culturally responsive services and advocates for members, develops relationships, and maintains communication with members and providers.
• Serves as a trusted, reliable, non-judgmental resource.
• Assists with self-management of chronic conditions including lifestyle strategies, risk factors, self-monitoring, medications, treatment adherence, health promotion, and screening recommendations.
• Conducts home visits to assess barriers to healthy living and healthcare access.
• Facilitates medical, behavioral, and dental office visits
• Explains the importance of keeping scheduled visits, reminds members of scheduled visits, and accompanies members to office visits
• Develops activities to improve member self-sufficiency by fostering member self-management skills resulting in the creation of goals and action plans.
• Provides culturally responsive services and advocates for members, develops relationships, and maintains communication with members and providers.

Skills on Resume: 

• Policy Adherence (Hard Skills)
• Liaison Coordination (Soft Skills)
• Resource Knowledge (Hard Skills)
• SDoH Screening (Hard Skills)
• Care Coordination (Soft Skills)
• Cultural Responsiveness (Soft Skills)
• Chronic Condition Management (Soft Skills)
• Home Visit Assessment (Soft Skills)

Job Summary: 

• Assists in the assessment of high-risk patients and identifies potential health risks and gaps in non-medical needs 
• Utility assistance, food, medications, transportation, and other potential needs that can be coordinated using community-based resources
• Works with the health care team on patients considered to be high risk due to their clinical condition or non-medical needs that may interfere in the management of the plan of care
• Supports the plan of care through in-office interviews and discussions as well as using home-based visits to foster communication and identification of other health risks or needs
• Attends appointments with the patients to assist in language interpretation as well as the interpretation of outcomes and needed follow-up activities
• Educate, coach and empower patients and families
• Regularly documents all CHW activities in the patient record/practice site EHR
• Participates in data collection and reporting activities, and communicates regularly with the care team
• Works with social work resources to help meet members' health and welfare needs
• Facilitates timely responses to requests for personal care services.
• Conducts home visits to assess barriers to personal care services, healthy living and healthcare access.
• Provides support to locate personal care service providers by members and agencies.
• Demonstrates knowledge of and performs all assigned tasks by UPHP plans, policies, and procedures, as well as accrediting and regulatory requirements.
• Participates in departmental and interdepartmental process improvements, and recommends improvements in clinical processes as opportunities are identified.
• Maintains confidentiality of member and client data.

Skills on Resume: 

• Risk Assessment (Hard Skills)
• Community Resource Coordination (Soft Skills)
• High-Risk Patient Support (Soft Skills)
• Care Plan Facilitation (Soft Skills)
• Language Interpretation (Soft Skills)
• Patient Education (Soft Skills)
• Documentation (Hard Skills)
• Process Improvement (Soft Skills)

Job Summary: 

• Communicates to clients the purpose of program services and the potential impact of those services on their health and well-being.
• Assists clients with the development of health management plans and goals.
• Assists clients in understanding care plans and instructions, accessing needed services, and navigating of health care systems, including the securing and use of a medical home to improve access to necessary medical care and social services.
• Coaches clients in the effective management of chronic health conditions and self-care, while motivating them to be active, engaged participants in their overall health.
• Facilitates individual and/or group education and support programs, to improve client skills for self-management of chronic conditions and to promote healthy lifestyle behavior changes.
• Assists with data collection and reporting by established MetroHealth guidelines.
• Works independently and/or collaboratively within a team.
• Builds and maintains positive working relationships within a care team, including, but not limited to care coordinators, social workers, community health advocates, clients, and providers.
• Works effectively with individuals from diverse backgrounds in reducing cultural and socio-economic barriers between clients and available institutional resources.
• Works with specific populations to improve health outcomes by bridging access to health care services and addressing social determinants of health.
• Assists clients in navigating systems that provide services to address non-medical needs that influence overall health.
• Identifies and responds to gaps in support services at the institutional and neighborhood levels that are necessary for good health.
• Engages with clients in a variety of environments, including their homes, neighborhood locations, community-based organizations, and MetroHealth facilities.
• Keeps current with emerging developments and changing trends in the field by participating in continuing education courses, professional organizations and seminars
• Reading current literature, and maintaining professional contacts within the community.

Skills on Resume: 

• Program Communication (Soft Skills)
• Health Management Planning (Soft Skills)
• Care Navigation (Soft Skills)
• Chronic Condition Coaching (Soft Skills)
• Group Education (Soft Skills)
• Data Collection (Hard Skills)
• Team Collaboration (Soft Skills)
• Cultural Competency (Soft Skills)

Job Summary: 

• Demonstrates competencies defined in Outreach Coordinator responsibilities in providing age-appropriate care to patients from birth to age 21, and select adult patients.
• Assesses communities to determine those community, business, and health organizations with which Children's Hospital should liaison and those events in which there should be participation to strengthen hospital relationships.
• Assesses opportunities for collaborative programs and services in health care, education, advocacy, and research with other community-based organizations, such as health care providers, child-serving agencies, businesses, and neighborhood groups.
• Assist in monitoring the delivery of services to ensure targeted outcomes are achieved and tracked.
• Provide brief risk counseling services to women, youth, and children identified as high risk for HIV/STI
• Participates in the development of collaborative programs by working with community-based organizations and with hospital clinical and administrative staff to design programs, develop affiliation agreements and contracts, and secure program resources.
• Represents Children's Hospital with other community health care providers and community organizations and liaisons to selected groups.
• Supports the philosophy and objectives of Children's Hospital and interprets these to other community health care providers, community organizations, hospital staff, patients, and parents.
• Participates in hospital committees and community-based committees and on boards and advisory groups as appropriate.
• Assist in the development of tools for measurement of the effectiveness of the outreach program and provide quarterly reports evaluating the effectiveness of the program.
• Develops and maintains expertise in best prevention practices in the area of specialty.
• Maintains an awareness of developments and issues in the community, which could affect the hospital and communicates these
• Remains knowledgeable about current research related to primary and other ambulatory care and applies principles
• Promotes own professional growth and development through continued education programs and current literature.

Skills on Resume: 

• Community Assessment (Soft Skills)
• Program Collaboration (Soft Skills)
• Service Monitoring (Hard Skills)
• Risk Counseling (Soft Skills)
• Program Development (Soft Skills)
• Community Liaison (Soft Skills)
• Effectiveness Evaluation (Hard Skills)
• Professional Development (Soft Skills)

Job Summary: 

• Initiates telephone or face-to-face contact with participants to describe the research study group, and explain the process of working with the CHW.
• Schedules and completes initial assessment and follow-up phone calls for enrolled patients within specified timeframes.
• Works with participants to set goals around healthy eating and physical activities and motivates them to achieve those goals.
• Teaches key educational messages in person and over the phone, and documents all activities in the study database.
• Reinforces educational messages regarding weight management by linking clients with supportive community services and programs.
• Records and monitors the participants' progress toward goals within specific timeframes, and documents relevant study visit activities.
• Assists participants with making follow-up appointments for the health coaching sessions.
• Demonstrates sensitivity and respect for the culture of the participant.
• Participates in regular training activities and attends regularly scheduled supervision and other research study-assigned meetings.
• Prepares reports, and documents and demonstrates the ability to function within an interdisciplinary team
• Provide general administrative duties including making follow-up appointments for participants, making reminder phone calls, and maintaining contacts and the study database.
• Work with community partners to ensure effective and efficient events, including events at HHI headquarters
• Support outreach, feedback, and communication efforts to drive vaccination objectives, including vaccination rates of families and children 12 years and older
• Provides prevention education to groups and individuals 

Skills on Resume: 

• Participant Outreach (Soft Skills)
• Goal Setting (Soft Skills)
• Educational Messaging (Soft Skills)
• Progress Monitoring (Soft Skills)
• Appointment Scheduling (Hard Skills)
• Cultural Sensitivity (Soft Skills)
• Report Preparation (Hard Skills)
• Administrative Support (Hard Skills)