• Promote timely access to appropriate care
• Increase utilization of preventative care, reduce emergency room utilization and hospital readmissions
• Provide medication reconciliation
• Assess patient’s unmet health and social needs
• Develop a care plan with the patient, family/caregiver, and providers and monitor adherence to these care plans evaluating effectiveness, patient progress, and facilitating change as needed

• Facilitate patient access to appropriate medical and specialty providers
• Educate patient and family/caregivers about relevant community resources
• Cultivate and support primary care and specialty provider co-management with timely communication, inquiry, follow up, and integration of information into the care plan regarding transitions-in-care and referrals
• Assist in the identification of high-risk patients
• Implement an effective internal tracking system for identified patients
• Promote health behaviors in all populations and ensure navigation assistance with community resources
• Ensure active tracking of test results, medication management, and adherence to follow-up appointments

Education

Must be a current licensed Practical or Registered Nurse or Medical Assistant

or have obtained a bachelor’s or master’s degree in Social Work

Minimum Work Experience

2 + years of experience in a clinic, hospital, or quality management environment

Required Skills, Knowledge, and Abilities

• Ability to identify and implement appropriate patient communication strategies and overcome accessibility barriers
• Experience in, and sensitivity to, the unique dynamics of an integrated hospital system
• Exposure to and participation with health IT systems and data reports
• Demonstrated skills in planning, organizing, decision making, analytical thinking, and communication required
• Demonstrated skills in Quality Improvement and operational improvements (e.g. “Lean”) methods.