Job Description

GENERAL OVERVIEW: This job will be responsible for helping patients to navigate and access medical care, community services/resources and develop healthy behaviors. The incumbent will act as a caring neighbor to help patients address the social, medical, and community problems that lead to poor health (social determinants of health). Will collaborate with medical providers to help patients deal with the 'real life' issues that keep them from staying healthy, help with tasks of getting medical care, and work on health goals by doing things like planning healthy meals and finding time to exercise. As a priority, interactions will promote, maintain, and improve the health of patients and their families. Provide social support, advocate for individuals and community health needs. Community outreach including home visits will be required. ESSENTIAL RESPONSIBILITIES Meet patients in a clinic or hospital and conduct a needs assessment by gathering information from the patient, family and medical provider. Assist patients to set health goals by working cooperatively with medical providers, case management departments and/or health plans to help ensure that patients have comprehensive and coordinated care. (25%) Responsible for establishing trusting relationships with patients and their families while providing general support and encouragement including motivating patients to meet their health goals. (20%) Make weekly follow up calls and home visits to patients in private homes and community settings to help patients connect to appropriate community agencies to address barriers like homelessness, substance abuse, hunger, transportation, child care, etc. (20%) Document each patient encounter in detail according to protocols and guidelines. (10%) Responsible for providing consistent communication to program supervisor/manager to evaluate patient/family status, ensuring that provided information and reports clearly describe progress and seeking regular supervision to discuss interventions and patient needs. (10%) Assist patients with completing application for benefits like insurance and food stamps and with organizing their records, making follow up appointments and filling prescriptions.(5%) Exhibit excellent working relations with patients, visitors, other AHN staff, providers, and other care team members effectively communicating AHN's mission. (5%) Knowledgeable about community resources appropriate to the needs of patients/families and ongoing utilization of resource database. (5%) Other duties as assigned. QUALIFICATIONS: Minimum Associate Degree in Social Services OR equivalent experience as a community leader (conducting outreach with high risk populations) or in human services or of volunteer work in high risk communities. 2 years experience living in, volunteering in, and/or working in high risk communities. Knowledge of local community resources (housing, food, support groups, financial assistance programs, utility assistance programs, etc.) Experience in outreach, customer service, social service, or a related field Excellent written and verbal communication skills. Ability to carry out written and oral instructions. Ability to exercise judgement in the application of professional services. Active listening skills; Social Perceptiveness; Interpersonal Skills; Organizational Skills Ability to collaborate with clinical professionals and medical providers or other members for the care team. Will need a basic understanding of clinical/medical terminology. Act 34 Criminal Background Clearance Certificate Act 33 Child Abuse Clearance Certificate Act 73 FBI Fingerprinting Criminal Background Clearance Certificate Preferred May require a valid Driver's license (depending on location). Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job. Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies. As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements. Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

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