Major Responsibilities:

Patient Outreach & Resource Navigation.

Establish relationships with patients/families and provide general support and encouragement.Conduct intake interviews with patients using established protocols and intake tools.Work with patients and their physicians to develop personal health action plans that are achievable.Assist patients in addressing challenges to care for transportation, language, family/social support.Assist patients with comprehension of health insurance eligibility, benefits and navigation.Schedule appointments and perform reminders for patients. Ensure appropriate resources are available for attending appointments.Follow up with patients by letter, phone call, text or home visit on missed appointments or referrals.Educate patients on self-care, healthy living, setting and achieving goals, using/reinforcing SUHI’s clinical education protocols, APP’s evidence-based tools or other, evidence-based tools.Refer patients to community-based resources to adhere to physician recommendations. Alert APP clinical team on patient needs, concerns, and interests. Ensure continuity of care.Keep accurate records of patient contacts and document patient needs, action plans, and follow up needs in appropriate databases or electronic medical record.

Health Education

Provide health education activities for identified health concerns such as Asthma, Diabetes, Hypertension and other chronic diseases.Provide informal counseling, education, and social support to assist patients with gaining access to continuous care and enabling services.Coach/encourage patient self-management and adherence to clinical recommendations for identified health concerns such as Asthma, Diabetes, Hypertension and other chronic diseases.

Community Outreach & Advocacy

Develop and maintain strong working relationships with external (e.g., referral sources and community agencies) and internal contacts (care team) through direct contact including participating in community meetings and care team huddles.Share information and resources, collaborate on initiatives and provide education to referral sources and community agencies to coordinate access to services.Collect and organize information to be used for current services and future community health education and outreach activities.

Program & Care Team Operations

Participating in the care team huddles to understand and proactively respond to the needs of the patient population.In collaboration with the clinical team, identify, consolidate and manage a high-risk patient registry.Assist the care team as needed and perform other duties as assigned.

Education/Experience Required:

High School Diploma/G.E.D. 2 years’ experience, preferably in a related area.

Knowledge, Skills & Abilities Required:

Good communication skills. Ability to work as a team member.Competent computer keyboard, laptop maneuvering, competent in Windows platformBasic computer skills and database entry.Good organizational skills.Ability to handle difficult calls and maintain professional conduct.Willingness to be flexible with job responsibilities

Physical Requirements and Working Conditions:

Spanish-speaking a plusAble to sustain full-time, 40 hours/week scheduleHold valid/active driver’s license , own or have consistent/dependable access to vehicle that meets daily task requirements with proof of active and lawful car insurance.Familiarity with and experience working in Chicago’s Northwest Side and Suburban Cook County communities (resident of Suburban Cook and Northwest communities preferred includes Niles, Des Plaines, Skokie, Dunning, Norridge, Park Ridge, etc.).Passion for and dedication to working with community members Excellent phone mannerismsAbility to effectively engage conversation, motivate and engage patients to participate in our program, and speak to all types of patients, particularly seniors.May need to flex daytime hours, M-F and possibly if needed to reach patients after standard work hours.If position has direct patient care or direct patient contact the following lifting requirement supersedes any previous lifting requirement effective 06/01/2015. Ability to lift up to 35 pounds without assistance.For patient lifts of over 35 pounds, or when a patient is unable to assist with the lift, patient handling equipment is expected to be used, with at least one other associate, when available.Unique patient lifting/movement situations will be assessed on a case-by-case basis.