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Conduct outreach to individuals in the clinic and community
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Build trusting, non-judgmental relationships with clients using a trauma informed approach
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Assist clients in accessing health care, behavioral health, housing, financial assistance, and community resources
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Advocate for client needs with service providers while supporting client autonomy
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Be an engaged team member of the Patient Centered Primary Care Medical Home care team
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Interviews clients/patients to obtain basic data, past medical history, etc.
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Implements individual and community assessment and treatment plans
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Deliver culturally relevant health education on topics such as preventative care, chronic disease management, sexual health, mental wellness, and substance use
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Support clients in understanding treatment plans, medication adherence, and self-management strategies
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Promote health literacy and help clients navigate insurance, benefits, and community systems
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Assist patients with paperwork and or referrals as needed
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Assist with MyChart navigation
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Assists in creating a positive and supportive work environment; enforces a safe workplace; establishes a culture of teamwork and communication; creates a workplace that promotes the organizational values and promotes an environment respectful of living and working in a multicultural society
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Foster and maintain up to date relationships with community partners, resources, organizations, and opportunities to remove barriers and ease access to services
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Follow up with patients who request resource assistance through the PRAPARE tool
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Meet with patients for warm hand-offs after primary care physician appointments to review and update care plan with Panel Care Coordinator and Integrated Behavioral Health Counselors
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Participate in daily huddles, case consultations, interdisciplinary care planning and team meetings
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Communicate client updates, barriers, and successes to medical, behavioral health, and social service staff
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Provide peer level insight into community needs and support care team decisions
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Participate in process improvement projects pertaining to this role
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When necessary, accompany patients to appointments
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Maintain accurate, timely, and complete documentation of all patient encounters and complete reporting requirements according to organization standards
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Track client contacts, referrals, outcomes, and care plans
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Follow HIPAA, 42 CFR Part 2, and organizational compliance requirements
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Follow up with patients when there are missed medical appointments and patient navigation sessions to initiate outreach and missed appointment procedures, as necessary.
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Attend and represent the organization at in-service trainings, meetings, and professional conferences at the request of or with the approval of supervisor
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Maintain strict confidentiality in accordance with agency policies
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Other duties as assigned
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Proficient with Microsoft office Suite
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Ability to learn and document within organizational electronic health record system
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Ability to handle crises and multiple tasks in a setting with a high volume of patients.
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Excellent communication skills
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Flexible and adaptable in response to changing patient and health care providers’ needs
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Commitment to the mission of care coordination
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Passionate, trustworthy, and empathetic when working with patient
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Able to assist in warm hand-offs, sometimes in person, from agency to agency and/or assist with appointments such as with the DMV, Tri-Met, etc.
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Ability to work independently with timely follow through
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Ability to complete all required documentation and information input in a professional, thorough, and timely manner
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Ability to effectively navigate technologies used in this position including Epic OCHIN, MS Office Applications, and Windows Server
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Ability to travel to various sites, outreach, community, and networking events
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Ability to work with people from diverse backgrounds
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Ability to provide timely, effective, and efficient customer service to the community, clients, and other employees
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Ability to interact patiently with individuals making inquiries regarding various programs and services who may have little or no experience or knowledge of services provided
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Ability to communicate and express ideas effectively both orally and in writing with co-workers and community partners
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Time management skills, multitasking, and ability to work under pressure to meet deadlines
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Ability to learn and perform health screening tests that require simple math
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Ability to adhere to professional boundaries and ethics
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Must adhere to Federal and State OSHA guidelines, including timely completion of mandatory trainings
