• Works within the community providing outreach to patients with complex medical and social needs • Acts as a resource to assist patients in navigating the health care system • Orients and assesses new Community Health Workers • Provides regular assessment of the level of proficiency demonstrated by staff during the orientation period in order to support decisions to move staff along in training or refocus until proficiency is met • Assists in the identification and outreach of medically complex patients • Collaborates with the multidisciplinary team in the development and implementation of the care plan • Engages patients by way of phone call, home visit, hospital visit, and accompanying patients to Providers appointments as needed • Completes vital signs • Identifies gaps in care and connects members with resources • Facilitates telemedicine visits with members and providers • Performs disease specific education • Conducts Medication Review to ensure medication adherence • Conducts safety evaluations in patients home • Facilitates adherence to treatment plan by early identification and resolution of gaps in care • Communicates all concerns to clinical team and manager as necessary, seeking support and guidance proactively • Participates in multidisciplinary team conference in order to maximize the treatment plan • Provides reinforcement of the treatment plan under the direction of the Case Manager and Licensed Social Worker and is available for consultation and case review as needed