This position requires working 2-3 days in person at St. Agnes Ascension in Baltimore, MD.

Summary/Position Objectives:

Under indirect supervision, works closely with medical providers, primary care teams, and social services agencies to provide short term care coordination and connection to resources and support to program clients to improve their health and general well-being through education and provision of coordination of care and services—works in both clinical and community-based settings, including client’s homes.

Responsibilities:

Essential Functions:

• Communicates to clients/patients the purposes of the program and the impact it may have on their well-being. Help patients identify socio-economic issues that affect their overall health and develop health/social management plans and goals.
• Documents all client encounters and contracts made on behalf of clients; completes and submits monthly reports; maintains comprehensive electronic client files.
• Educates clients on the proper use of the Emergency Room and provides information about alternatives. Coaches patients in effective management of their chronic health conditions and self-care.
• Assists clients in assessing health-related services, including but not limited to obtaining a medical home, providing instruction on appropriate use of the medical home, overcoming barriers to obtaining needed medical care and/or social services.
• Provides support and advocacy during an initial medical visit or when necessary to assure clients’ medical needs and referrals required are being conveyed.
• Facilitates client access to community resources, including locating housing, food, clothing, parenting, and providers for each life skills, and relevant mental health services. Assists clients in utilizing community services, including scheduling appointments with social services agencies, and assisting with completion of applications for programs for which they may be eligible.
• Facilitates communication and coordinates services between providers and the clients/patients. Coordinates and monitors services, including comprehensive tracking of clients’ compliance in relation to care plan objectives.
• Builds and maintains positive working relationships with clients, providers, nurse case managers, agency representatives, and office staff from diverse cultural and socio-economic backgrounds. Works to reduce cultural and socio-economic barriers between clients and institutions.

Secondary Functions:

• Observe confidentiality of member records in accordance with MPC policies and procedures.
• Must be available and willing to travel to such locations and with such frequency as the employer determines is necessary or desirable to meet its business needs. Possession of a valid Maryland State Driver’s License is a requirement for this position.
• Work requires incumbent who provides such services in patient care or clinical areas, and is required to be fully vaccinated, “proof of vaccination” required for this position.

Knowledge and Skills:

• Strong interpersonal and communication skills and the ability to work effectively with a wide range of constituencies in a diverse community.
• Knowledge of community agencies and resources.
• Working knowledge of multi-system outreach programs related to health care delivery, clinical education, and health-related services.
• Ability to plan, implement, and evaluate individual client care plans.
• Knowledge of transportation and other barriers to care that may be encountered by the client.
• Ability to communicate medical information to health care professionals and care coordinators over the telephone.
• Skill in organizing resources and establishing priorities.
• Creative and analytical thinking; solid written and oral skills.
• Strong problem solving, organizational, and time management skills.
• Computer literate, Microsoft Office preferred.

Education and Work Experience:

• High school diploma or GED; at a minimum of 2 years’ experience in serving the Medicaid population, preferably in the MD/DC area. Community Support Worker (CSW) or Certified Peer Support Worker (CPSW) certification preferred.

Positions Reporting:

None