• Support a successful transition from the carceral setting to the community • Identify barriers to healthcare and social services and connect members to resources to optimize the members health • Collaborate with the Carceral Transitions team, facility staff and community to ensure a success re-entry into the community for the member • Build individual and community capacity by increasing health knowledge and self-sufficiency through outreach, community education and referrals, peer support and advocacy • Advocate on behalf of and facilitate coordination of resources required to help justice involved members reach optimum functional levels upon reentry to the community during transition and provides short-term care coordination • Communicate the members health care needs with the carceral facility and send medical records if required • Identify Health Related Social Needs and connect members to appropriate community resources • Meet with the members via phone or video conferencing at city and county jails, or the Department of Corrections • Coordinate medical, dental, and/or vision appointments in accordance with the members release date including transportation to appointments if required • Provide verbal and/or written status updates regarding the members progress and needs to responsible case managers and providers, legal mandate, or other care plan affiliates as needed to assist the program and members • Ensure case documentation is consistent with policies and procedures • Complete Health Risk Assessments with members

• 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

• Acts as a bridge between health care providers, community-based providers, and individuals in the community • Understands experiences, socioeconomic needs, language, and/or culture of the communities served • Spends time outreaching, providing health education, and helping patients navigate health systems • Identifies barriers to care and assists in changing service delivery to improve patient and community health • Builds individual and community capacity by increasing health knowledge and self-sufficiency through outreach, community education, social support, and advocacy • Serves as a liaison between communities and health care systems/agencies • Provides guidance and social assistance to patients and the entire care team • Enhances patients' ability to effectively communicate with healthcare providers and care team members • Provides culturally and linguistically appropriate health education using evidence-based sources • Advocates on behalf of patients, families, caregivers, and communities to obtain needed care and/or resources • Informs health care providers and care team members of barriers and challenges limiting patients' abilities • Establishes and maintains collaborative relationships with community-based organizations and across the care continuum