Job Summary Provides support for delivering integrated, whole-person care coordination to members engaged through community-based mobile services. Responsible for independently assessing and triaging member needs, creating real-time member care plans, addressing barriers to care, coordinating clinical and social services across the continuum, and ensuring safe and effective mobile unit operations to support care delivery. Improves access, enhances quality outcomes, and connects members with the services they need in community settings. Contributes to overarching strategy to provide quality and cost-effective member care. Job Duties Plays a key role in improving access, enhancing quality outcomes, and connecting members with the services they need in community settings. Serves as the primary point of contact for members on the mobile unit. Conducts non-clinical assessments to identify medical, behavioral health, and social needs. Conducts eligibility screening and facilitates registration for mobile services in the electronic medical record (EMR). Develops and updates individualized care plans in coordination with providers, care managers, and interdisciplinary team members. Identifies barriers to care and implements interventions to facilitate access, adherence, and follow-up care. Coordinates referrals to clinical services, specialty care, behavioral health, and social support agencies. Collaborates closely with licensed care managers, clinicians, leadership, and interdisciplinary partners. Participates in care team huddles and case discussions. Connects members to resources addressing social determinants of health (e.g., food, housing, transportation, behavioral health, financial assistance). Documents member interactions, care plans, and follow-up actions within internal documentation systems. Provides motivational interviewing, health system navigation, and resource counseling. Assists members with paperwork, enrollment, and benefit navigation. Provides education on available services, community programs, and care pathways. De-escalates challenging situations and responds with trauma informed, culturally sensitive communication. Maintains up-to-date knowledge of local community organizations and service networks. Builds partnerships with community agencies to strengthen member support options. Represents the mobile medical program at community events and collaborates with external partners. Safely drives and positions the mobile medical unit at scheduled locations. Performs routine pre/post-trip inspections and minor maintenance. Coordinates routine and unexpected mobile unit maintenance, ensuring timely repairs and minimal disruption to care delivery. Ensures a safe and welcoming environment for members accessing on-site services. Collaborates with various departments to ensure operational readiness for community deployment. Manages medical supply and administrative inventory to ensure adequate stock levels for mobile clinic operations. Maintains quality logs for clinical tools and equipment to ensure compliance with safety and quality standards. Provides guidance to staff or volunteers supporting mobile unit activities.
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Job Type
Full-time
Career Level
Entry Level
Education Level
No Education Listed