Major Responsibilities:

Patient Outreach & Resource NavigationProvide intensive outreach efforts by conducting home visits or visits to other appropriate settings to an identified patient population.Establish relationships with patients/families and provide general support and encouragement.Conduct intake interviews with patients using established protocols and intake tools.Work with patients and their physicians to develop personal health action plans that are achievable.Assist patients in addressing challenges to care for transportation, language, family/social support.Assist patients with comprehension of health insurance eligibility, benefits and navigation.Schedule appointments and perform reminders for patients. Ensure appropriate resources are available for attending appointments. Follow-up with patients by letter, phone call, text or home visit on missed appointments or referrals.Educate patients on self-care, healthful living, setting and achieving goals, using/reinforcing SUHI’s clinical education protocols, APP’s evidence-based tools or other, evidence-based tools. Refer patients to community-based resources to adhere to physician recommendations.Alert APP clinical team on patient needs, concerns, and interests. Ensure continuity of care.Keep accurate records of patient contacts and document patient needs, action plans, and follow up needs in appropriate database or electronic medical record.

Health Education

Provide health education activities for identified health concerns such as Asthma, Diabetes, Hypertension and other chronic diseases.Provide informal counseling, education, and social support to assist patients with gaining access to continuous care and enabling services.Coach/encourage patient self-management and adherence to clinical recommendations for identified health concerns such as Asthma, Diabetes, Hypertension and other chronic diseases.

Community Outreach & Advocacy

Develop and maintain strong working relationships with external (e.g., referral sources and community agencies) and internal contacts (care team) through direct contact including participating in community meetings and care team huddles.Share information and resources, collaborate on initiatives and provide education to referral sources and community agencies in order to coordinate access to services.Collect and organize information to be used for current services and future community health education and outreach activities.Program & Care Team OperationsParticipate in care team huddles to understand and proactively respond to the needs of the patient population.In collaboration with the clinical team, identify, consolidate and manage a high-risk patient registry.Assist care team as needed and performs other duties as assigned

Education/Experience Required:

High School Diploma/G.E.D. 2 years experience, preferably in related area such as social services, public health, psychology

Knowledge, Skills & Abilities Required:

•Good communication skills.Ability to work as a team member as well as independentlyCompetent computer keyboard, laptop maneuvering, competent in Windows platform. Basic computer skills and database entry.Good organizational skills.Ability to handle difficult calls and maintain professional conduct.Willingness to be flexible with job responsibilities, ability to work on multiple duties at onceHold valid/active driver’s license , own or have consistent/dependable access to vehicle that meets daily task requirements with proof of active and lawful car insurance.

Physical Requirements and Working Conditions:

Able to sustain full time, 40 hrs/week schedule Able to navigate city driving/find specific residences.Passion for and dedication to working with community members.Excellent phone mannerismsAbility to effectively engage conversation, motivate and engage patients to participate in our program, and speak to all types of patients, particularly seniors.Spanish-speaking a plus

Schedule Information:

May need to flex daytime hours to stretch to 8pmM-F and possibly Saturday if needed to reach pts after work hours.8hr shifts/40hrs per week Able to Flex time to work on some weekends and some evenings due to community events, 2 days a week working with Walkers Point on specialty referrals with immigrant population, Outreach and coverage for Patient Engagement and Recovery Program as needed. Travel within Milwaukee area for possible home visits and community events.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.