SUMMARY: Provides care coordination and advocacy to patients, including outreach and engagement, development of the care plan, linkage of the patient with resources (food, housing, transport, financial, community based services) as well as linking the patient with care.

DUTIES & ESSENTIAL JOB FUNCTIONS: NOTE: The following are the duties performed by employees in this classification, however, employees may perform other related duties at an equivalent level. Not all duties listed are necessarily performed by each individual in the classification.

3. Assists in determining relevant goals and abilities which could include vocational or housing goals.

5. Pre-screens clients to determine health care/social service needs and communicates those needs to professional or paraprofessional personnel as necessary.

7. Monitor patient's adherence to health improvement or treatment plan

8. Coordinates any appropriate documentation (consents, assessment tools) to the staff or EHR.

11. Serves as a liaison between Alameda Health System and community groups by providing information concerning relevant health/social service/community based programs in Alameda County.

12. Coordinates patients care, such as arrange rides, appointment reminders, obtain medical records, communicate with specialty clinics, and care team consult.

13. Provides consultation and education to team members regarding patient/family (social determinants) issues and community resources.

14. Analyze client activities and integrate appropriate program activities/services; availability of community and governmental services and resources.

15. Coordinates patient care activities with other members of the healthcare team, the patient, the patient's representatives, and community partners and makes referrals as appropriate.

16. Maintains patient records, including patient assessments, plans interventions, patient/family involvement, outside agency communications and interdisciplinary contacts.

17. Prepares case reports; documents assessment, progress notes and related information as required by Medicare, MediCal, Title 22 and other mandated regulations according to Department standards; prepares correspondence regarding patient intake or follow-up.

MINIMUM QUALIFICATIONS:

Required Education: High School Diploma or G.E.D.

Preferred Education: Bachelor's degree in a related field (health, social science or a related field such as psychology or counseling) or an emergency technician program.

Required Experience: Three years of progressively responsible work experience in a community-based health care service capacity; or one year full-time experience in the class of Specialist Clerk or higher with AHS services performing similar duties, or the equivalent of two years of relevant full-time experience working in a community outreach program performing similar duties; experience with Electronic Health Records (EHRs) and Case Management applications, e.g. Midas or 3M. Preferred Experience: One year working in a community outreach program performing duties such as intake, peer counseling, assessments, program screening, placement and referral.

Licenses/Certifications: Valid California driver's license.