Position Responsibilities 

• Complete Health Risk Assessments (HRA) with patients living in target zip codes.
• Assist with community resources and scheduling appointments.
• Enroll eligible patients in disease management program(s) and provide disease-specific and preventive care patient education.
• Assist with crisis interventions following up on the PHQ9 assessments and monitor patients (in person or by telephone) at required frequencies and track clinical outcomes such as PHQ-9, blood pressure, HbA1c. Use a worklist to identify and re-engage patients who are not participating as expected in the disease management program.
• Communicate with multidisciplinary teams with patient updates and ensure the care plan is consistently updated and integrated with disease management information. Support the treatment plan prescribed by PCPs, focusing on treatment adherence, side effects, other complications, and effectiveness of treatment.
• Facilitate treatment plan changes for patients who are not improving as expected in consultation with the PCP. These may include changes in medications, treatments, or appropriate referrals for clinically indicated services outside the primary care clinic (e.g., social services such as housing assistance, vocational rehabilitation, subspeciality, mental health specialty care, substance abuse treatment, etc.).

• Encourage patients to become actively engaged in their own health by active outreach and compassionate communication.  Utilize techniques such as motivational interviewing and behavioral activation.

• Prepare for and participate in regularly scheduled caseload oversight with the Care Coordinator Supervisor. Communicate treatment recommendations to the multidisciplinary team, including patient’s PCP.
• Accurately document patient information, assessments, interventions, and encounters.
• Attend ongoing training and learning related to job position and duties.
• Schedule appointments, manage referrals, and coordinate with insurance companies.

Knowledge, Skills, and Abilities

• High school diploma or GED
• Strong interpersonal skills and demonstrate ability to collaborate and communicate effectively in a team setting.
• Punctual, reliable, and willing to learn, high energy, empathy, and organization skills
• Ability to effectively engage patients in a therapeutic relationship, when appropriate, by telephone or face-to-face.

• Experience with or ability to learn assessment tools and interventions for hypertension, diabetes and mild to moderate depression.
• Ability and opportunity to work flexible hours.
• Previous experience in health education.
• Experience working with patients who have diabetes, hypertension and/or depression.
• Basic knowledge of psychopharmacology for common mental health disorders that is within appropriate scope of practice for type of provider filling role.
• Working knowledge of evidence-based psychosocial treatments for common mental health disorders.
• Familiarity with brief, structured intervention techniques (e.g., Motivational Interviewing, Behavioral Activation) and evidence-based counseling techniques (e.g. CBT or PST), when appropriate.

Organizational Overview