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The position involves completing Health Risk Assessments (HRA) in the MHNConnect platform for patients who meet specific eligibility criteria, including those from Chicago's West side zip codes who are medically uninsured or have Medicaid. The role includes assisting patients with community resources, scheduling appointments, and enrolling eligible patients in disease management programs focused on Diabetes, Hypertension, and Depression. Responsibilities also include monitoring patients, supporting treatment plans prescribed by primary care providers (PCPs), and facilitating treatment plan changes when necessary. The position requires proactive outreach to engage patients in their health management and accurate documentation of patient interactions.