Under direct supervision, provides direct care services to patients as well as clinical support for the Maryland Primary Care Program (MDPCP) and other Value Based Performance Programs. Serves an important role in furthering care plans developed by providers, management of chronic disease, promotion of healthy behaviors and preventing unnecessary hospital utilization by, including but not limited to, performing in-home assessments, conducting SDOH patient screenings, helping patients and families navigate and access essential community resources, and conducting depression screenings; and other duties as assigned. ESSENTIAL FUNCTIONS Conducts in-home visits related to basic care continuity as well as following hospitalizations to facilitate care needs assessments in addition to closely working with providers to develop and execute chronic care management plans. Collects clinical data during home visits including but not limited to basic vital signs and weight. Conducts Social Determinant of Health Patient Screenings. Assists patients in setting personal health related goals and makes all scheduled health appointments. Helps patients and families identify and access pertinent community resources.
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Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED
Number of Employees
5,001-10,000 employees