Outreach and Engagement Specialist

Description

POSITION OVERVIEW:

Under the supervision of the Senior Manager of Population Health and Support Services the Outreach and Engagement Specialist provides support and linkage to services, advocacy, education, and information in order to ensure optimal health outcomes, increase access of services, and support the patient in self-management of health goals.  The Specialist also serves as a cultural bridge to the health care system aiding in identifying and supporting the patient’s cultural identity. The Specialist will also make independent decisions regarding patient access and education.

DUTIES:
•    Creates outreach strategies to ensure the most effective outreach is completed.
•    Provides and links patients with community resources and referrals. 
•    Documents all patient encounters in our EMR.
•    Outreaches to high-risk patients to ensure continuity of care.
•    Provides intensive case management for recently discharged patients.
•    Completes needs assessment including Social Determinants of Health for patients in cohort.
•    Provides Case Management services for high-risk patients.
•    Helps patient obtain transportation to necessary medical appointments via PT-1 forms, bus vouchers, cab vouchers and other resources.
•    Provides a cultural bridge between patients and the health care system.
•    Works within the Patient Centered Medical Home Model with primary care providers, Behavioral Health, home care providers, and other care team members on complex client situations.
•    Assists patients and family with identifying barriers and problem solve solutions.
•    Coaches patients and family on self-management skills.
•    Works with Behavioral Health to support to patients experiencing behavioral health issues.
•    Participates in various UCHC committees to address the complex needs of patients.
•    Participates in work groups to pilot strategies to increase arrival rates.
•    Completes outreach to patients who are newly and chronically lost to follow-up.
•    Works with Care Teams to assist people with new and chronic health illnesses such as Diabetes Mellitus, cardiac conditions, HIV, and others.
•    Participates with planned outreach/education activities in the community.
•    Identifies and help resolve potential/actual crises in collaboration with multidisciplinary team.
•    Provides cross-cultural interpreter services and education for patients and providers.
•    Provides assistance to non-English speaking patients throughout the care continuum.
•    Conducts home after consultation with care teams and management.
•    Documents patient/collateral contacts in the EHR and maintain statistics.
•    Participates in quality improvement projects within department and interdepartmentally as needed.
•    Attends in-service trainings and outside seminars, as indicated.
•    Performs other related duties as required.
•    Attends community meetings as needed.
 

Qualifications

•    Bilingual in English and Spanish or Cape Verdean Creole, or Vietnamese.
•    B.A or B.S in related field or equivalent experience in health and human services.
•     Excellent interpersonal, computer and writing skills as well as a desire to work in a helping profession with people in need.
•    Evening and weekend flexibility in order to attend potential health fairs.