• Responsible for providing ongoing case management services for participants enrolled in ACCESS; works with participants to enhance stability and overall well-being by addressing participant needs, including community resources, assistance with internal and external referrals for medical, substance use, mental health, parenting, employment, housing needs, and other needs related to social determinants of health.
• Identifying, facilitating and securing access to needed healthcare, social services benefits and community resources; conduct initial assessments and develop care plans.
• Participate in community events and meetings to recruit participants, identify resources, and build relationships with partner organizations; Distribute public education materials to a targeted audience; Distribute information about community events and important resources.
• Become familiar with the ACCESS Harris IBM Portals (Provider Portal, Client Portal, and Watson Care Manager) and enroll potential participants and their family members; Follow up with community members regarding appointments, community activities, and forms to ensure they’re adequately completed.
• Will have an assigned caseload and will monitor the case for the duration of the program and will be responsible for the assessment and case management of the ACCESS program participants to ensure an appropriate level of care and develop a participant care plan.
• Conduct site/home visits as needed to complete initial assessments on new participants and provide follow-up to existing participants.
• Accompany participants to medical, housing, and other needed appointments, and any other in-field support requested; communicate with members of the community, colleagues effectively and efficiently; provide health education and support.
• Regularly coordinating and communicating with Care Team members on all care plan activities, including referrals, transition care planning, and follow-up tracking; coordinate with healthcare providers and community resources.
• Monitor progress and evaluate outcomes; document and maintain accurate records.
• Other duties as assigned, including responding to an emergency event. 

This position is subject to a criminal history check. Only relevant convictions will be considered and, even when considered, may not automatically disqualify the candidate.

• Bilingual (English/Spanish) 

• This is a full-time position- 40 hours per week (including evenings and weekends).
• Ability to work outside regular business hours (evenings and weekends) is required.
• May be required to travel which may include transporting clients, participating in community outreach programs, and attending meetings and training opportunities.

• This job operates in a professional office environment.
• This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets, and fax machines.
• This job requires attending periodic events in the community.

• Frequently required to sit or stand, use manual dexterity, speak, listen, hear, and write
• Works in an office or indoor environment with little or occasional light physical effort and moderate noise
• May occasionally lift and move up to 25 pounds and occasionally lift to 50 pounds

• Harris County Public Health/ACCESS Harris County: 1111 Fannin St, Houston, TX 77002