GENERAL SUMMARY

Provide direct care services to patients as well as clinical support for the Maryland Primary Care Program (MDPCP) and other Value Based Performance Programs. They will serve an important role in furthering care plans developed by providers, management of chronic disease, promotion of healthy behaviors and preventing unnecessary hospital utilization by, including but not limited to, performing in-home assessments, conducting SDOH patient screenings, helping patients and families navigate and access essential community resources, and conducting depression screenings.

ESSENTIAL FUNCTIONS

• Provides general information to individuals and families on program objectives and services, eligibility requirements and benefits, confidentiality of information, etc. Distributes informational materials and literature.
• Schedules clients for appointments with health care providers. Reminds them of pending appointments and contacts them to inquire into reasons for missed appointments. Escorts clients to various appointments to ensure compliance and provide support.
• Assists clients in obtaining necessary transportation and/or childcare when treatment is needed.

DEPARTAMENTAL ESSENTIAL FUNCTIONS

• Will conduct in-home visits related to basic care continuity as well as following hospitalizations to facilitate care needs assessments in addition to closely working with providers to develop and execute chronic care management plans.
• Collection of clinical data during home visits including but not limited to basic vital signs and weight
• Conducts Social Determinant of Health Patient Screenings.
• Assist patients in setting personal health related goals and make all scheduled health appointments
• Help patients and families identify and access pertinent community resources
• Provide effective patient education to promote and adopt healthy behaviors
• Assists with care coordination of Medicare beneficiaries.
• Exhibits compassion and empathy for all patients and families at all times.
• Timely and accurate clinical documentation in EPIC related to patient care encounters.
• Utilizes appropriately and accurately the electronic system to perform required duties.

EDUCATION and/or EXPERIENCE

•  High School Diploma or equivalent required.
• Two years’ work experience providing outreach services. Experience should include writing reports and maintaining records.

• Completion of an accredited Community Health Worker training program is preferred.