Responsibilities will include:
1. Keeping a population health registry for preventive care
2. Educating patients regarding needed preventive care screenings
3. Educating patients about self-management of diabetes, hypertension and coronary artery disease that focuses on life-style changes: diet, nutrition and exercise as well as appropriate tests and studies (ie eye exams)
4. Healthcare navigation assistance for health center patients to ensure that connection with the correct provider and follow up
5. Creating and maintaining patient databases, resource listings with contact information
6. Creating and sending appointment reminders for patients that frequently miss scheduled PCP and specialist appointments.
7. Attending weekly multidisciplinary team meetings to case manage challenging patient needs
8. Attending weekly MAT (medication assisted treatment) team meetings set up to case manage our patients on various treatments for alcohol and opiate addiction
9. Attending monthly Integrated Behavioral Health team meetings
10. Evaluate and initiate appropriate referrals for assistance through County, State, and Federal programs when needed

• Brief health education to patients
• Coordinating with other programs to provide health classes
• Requesting medication refills for patients already enrolled
• Attending meetings and patient huddles
• Collaborating with leadership to meet needs of materials
• Developing assessment tools to track patient improvement
• Coordinating for resource distribution with other programs
• Scheduling and coordinating communication for outreach visits
• Assessing community data to locate areas that would benefit from community health screenings and referrals
• Finding additional community resources and programs for patients
• Coordinating patient care with the physicians through in-person or EHR communication .

• Self-starter
• Flexible
• Multi-tasker, able to balance multiple priorities
• Detail-oriented
• Community engagement/outreach skills

Knowledge of AmeriCorps/Health Corps member requirements. Skill with Microsoft Office or other software for a variety of data processing operations involving a range of problem solving, record keeping, correspondence, and service tracking options.

Member uses initiative in carrying out recurring assignments following set procedures, independently. The supervisor assigns service activities in terms of project objectives and basic priorities and is available for consultation in resolving controversial issues.

The member independently plans and carries out the projects and selects the approaches and methods to be used in solving problems.

Detailed guidelines exist, including regulations and directives, handbooks, precedents, industry standards, and files of previous projects. Guidelines are generally applicable, but the member independently makes adaptations in dealing with problems and unusual situations.

Member has to develop, analyze, or evaluate information before the service position can progress. In making decisions, the member is often required to depart from past approaches and to extend traditional techniques.

Personal vehicle required.

Proficiency in a language other than English is NOT required?