Serves as a bridge between the health system and patients, particularly patients with Medicare and/or Medicaid and patients with identified social needs. Works to promote, maintain, and improve health and well-being through informal support and counseling to their patients. Uses culturally appropriate outreach, support, and navigation to help patients access health care and address identified social needs. Plays a key role in building individual capacity by increasing patient’s health knowledge and self-sufficiency through a range of activities such as health education, goal setting, motivational interviewing, and advocacy. Works collaboratively with other healthcare team and community-based providers to improve patient health outcomes and reduce racial, ethnic, and economic disparities in those outcomes. ESSENTIAL FUNCTIONS 1. Knows, understands, incorporates, and demonstrates the Trinity Health Mission, Vision, and Values in behaviors, practices, and decisions. 2. Delivers high-value services to patients, such as coordination of care, accompaniment to appointments, and outreach, in clinical and community-based settings. Works with an assigned patient caseload to provide support, advocacy, and referrals to community-based services. Assesses patients for social needs and barriers to available resources and services. Helps patients navigate and gain access to appropriate health care/social services and other community resources. Provides basic education regarding health promotion to increase understanding and encourage adopting healthy behaviors. Shares insight and expertise such as patients’ customs/beliefs with providers and works collaboratively to promote culturally appropriate services. 3. Utilizes multiple system applications for caseload management, data collection, and reporting. Uses Electronic Health record and embedded tools for care coordination and documentation. Uses applicable resources, services, and processes to complete relevant referrals and applications in a timely manner. Collaborates on performance improvement activities as indicated by program outcomes and patient experience. Incorporates basic knowledge of Trinity Health policies, practices & processes to ensure quality, confidentiality & safety are prioritized. Demonstrates knowledge of departmental processes & procedures & ability to readily acquire new knowledge. 4. Employs effective & respectful written, verbal & nonverbal communications; Develops an environment of mutual confidence & trust through collaborative relationships; Effectively communicates goals, standards, program expectations, service performance & how the work serves Trinity Health objectives. Serves as a liaison between providers and patients to improve communication and coordination of services. Provides support to patients via phone and in-person interactions at patient’s home, community, or clinic setting. 5. Performs work in a caring, collaborative & safe manner that complies with regulatory standards. Maintains a safe, functional & organized workspace environment. Stewards productive use of resources (e.g., people, financial, equipment, supplies, materials) to achieve assigned commitments, experiences & quality standards. Responsible for continuous role-based self-development & leadership growth. Supports the professional growth of team members. Self-monitors & initiates corrections and/or seeks assistance or guidance when needed. 6. Other duties as needed and assigned by the supervisor. 7. Maintains a working knowledge of applicable Federal, State, and local laws and regulations, Trinity Health’s Organizational Integrity Program, Standards of Conduct, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical, and professional behavior.
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Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED
Number of Employees
251-500 employees