SUMMARY: Provides care coordination and advocacy to patients, including outreach and engagement, development of the care plan, linkage of the patient with resources (food, housing, transport, financial, community based services) as well as linking the patient with care.

DUTIES & ESSENTIAL JOB FUNCTIONS: NOTE: The following are the duties performed by employees in this classification. However, employees may perform other related duties at an equivalent level. Not all duties listed are necessarily performed by each individual in the classification.

1. Administers risk assessment or intake interviews with patients and/or families and records this assessment in the patient's medical record; assesses patient's level of functioning, environment, appropriateness and adequacy of support system related to illness and ability to cope.

2. Analyze client activities and integrate appropriate program activities/services; availability of community and governmental services and resources.

3. Assists in determining relevant goals and abilities which could include vocational or housing goals.

4. Assists with coordination and delivery of preventive health care programs or in coordination of housing or vocational placement.

5. Coordinates any appropriate documentation (consents, assessment tools) to the staff or EHR.

6. Coordinates patient care activities with other members of the healthcare team, the patient, the patient's representatives, and community partners and makes referrals as appropriate.

7. Coordinates patients care, such as arrange rides, appointment reminders, obtain medical records, communicate with specialty clinics, and care team consult.

8. Intervenes with patients and patient's representatives regarding emotional, behavioral, and financial barriers to current illness and/or disability.

9. Maintains patient records, including patient assessments, plans interventions, patient/family involvement, outside agency communications and interdisciplinary contacts.

10. Monitor patient's adherence to health improvement or treatment plan

11. Prepares case reports; documents assessment, progress notes and related information as required by Medicare, MediCal, Title 22 and other mandated regulations according to Department standards; prepares correspondence regarding patient intake or follow-up.

12. Pre-screens clients to determine health care/social service needs and communicates those needs to professional or paraprofessional personnel as necessary.

13. Provides consultation and education to team members regarding patient/family (social determinants) issues and community resources.

14. Screens for any barriers to care such as substance abuse, neglect or housing.

15. Serves a resource and provides counseling and treatment related to Substance Abuse or palliative care or end of life planning.

16. Serves as a liaison between Alameda Health System and community groups by providing information concerning relevant health/social service/community based programs in Alameda County.

17. Serves as a resource and coordinates access local community resources and effectively assists families and patients in accessing appropriate resources to meet identified needs; coordinates referrals for patients of community services available and may contact those agencies/community-based organizations on clients' behalf; identifies and connects patients to community resources that will assist them in achieving good health outcomes; recruits volunteers to attend drug treatment programs at participating drug treatment centers.

MINIMUM QUALIFICATIONS:

Preferred Education: Bachelor's degree in a related field (health, social science or a related field such as psychology or counseling) or an emergency technician program.

Preferred Experience: One year working in a community outreach program performing duties such as intake, peer counseling, assessments, program screening, placement and referral.

Required Education: High School Diploma or G.E.D.

Required Experience: Three years of progressively responsible work experience in a community-based health care service capacity; or one year full-time experience in the class of Specialist Clerk or higher with AHS services performing similar duties, or the equivalent of two years of relevant full-time experience working in a community outreach program performing similar duties; experience with Electronic Health Records (EHRs) and Case Management applications, e.g. Midas or 3M.

Required Licenses/Certifications: Valid California driver's license.