Job Description:

• Coordinate care for an assigned patient caseload.
• Collaborate with patients, families, caregivers, healthcare providers, and partners to address complex social needs.
• Facilitate communication among healthcare teams to ensure integrated and effective care.
• Support patients and families with emotional, social, and financial challenges.
• Conduct home visits as needed, adhering to safety policies.
• Connect patients with family and community resources to meet social care needs.
• Accurately document interventions, including clinic visits, home visits, calls, and texts.
• Onboard patients and assist with medical and social care visits.
• Educate patients on managing acute and chronic conditions.
• Provide guidance and build confidence to support patient health management.
• Communicate via in-person visits, calls, video, and texts.
• Work with multidisciplinary teams, including care transition and Medicaid case managers.

Must Haves:

• Community Health Worker Certification
• Bilingual in English and Spanish
• 2+ years of experience in working in the healthcare field
• High School Diploma or GED