• Conducts in-home, clinic-based, telephonic, and community-based wellness visits with patients/members as assigned.
• Completes health risk assessments, social needs screenings, and follow-up activities to identify barriers related to health care access, food, housing, transportation, medication access, safety, utilities, and other social drivers of health.
• Provides support, education, and reinforcement to help patients/members understand and follow their individualized care plans.
• Supports medication adherence by providing reminders, identifying barriers to medication access or understanding, and escalating concerns to the appropriate clinical team member.
• Assists patients/members with appointment reminders, follow-up care needs, preventive screenings, immunizations, routine checkups, and appropriate use of their medical home.
• Facilitates transitions of care after hospital, emergency department, or skilled nursing facility discharge by assisting with outreach, follow-up needs, appointment coordination, resource connection, and escalation of concerns.
• Connects patients/members to appropriate internal and external resources.
• Helps patients/members access community-based resources, including food assistance, housing support, transportation resources, utility assistance, financial assistance programs, and other social service supports.
• Assists patients/members with completion of forms, applications, resource referrals, and follow-up steps needed to access programs or benefits for which they may be eligible.
• Serves as a trusted liaison between patients/members, families, community organizations, health care providers, clinics, and social service agencies.
• Builds positive, supportive relationships with patients/members while promoting engagement, self-management, and active participation in health and wellness goals.
• Documents all encounters, outreach attempts, assessments, identified needs, interventions, referrals, and follow-up activities in the appropriate electronic system according to departmental expectations.
• Escalates concerns related to safety, unmet social needs, changes in health status, behavioral health concerns, medication concerns, suspected abuse/neglect, or barriers requiring clinical or social work intervention to the appropriate team member.
• Maintains current knowledge of community resources, health care services, payer resources, internal programs, and referral pathways.
• Works collaboratively and effectively within a team while also demonstrating the ability to work independently in community-based settings.
