Major Responsibilities: Patient Outreach & Resource Navigation     1)Provide intensive outreach efforts by conducting home visits or visits to other appropriate settings to an identified patient population.     2)Establish relationships with patients/families and provide general support and encouragement.     3)Conduct intake interviews with patients using established protocols and intake tools.     4)Work with patients and their physicians to develop personal health action plans that are achievable.     5)Assist patients in addressing challenges to care for transportation, language, family/social support.     8)Assist patients with comprehension of health insurance eligibility, benefits and navigation.     6)Schedule appointments and perform reminders for patients. Ensure appropriate resources are available for attending appointments.     7)Follow-up with patients by letter, phone call, text or home visit on missed appointments or referrals.     9)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.     10)Refer patients to community-based resources to adhere to physician recommendations. 11. Alert APP clinical team on patient needs, concerns, and interests. Ensure continuity of care. 12. Keep accurate records of patient contacts and document patient needs, action plans, and follow up needs in appropriate database or electronic medical record. B. Health Education     1)Provide health education activities for identified health concerns such as Asthma, Diabetes, Hypertension and other chronic diseases.     2)Provide informal counseling, education, and social support to assist patients with gaining access to continuous care and enabling services.     3)Coach/encourage patient self-management and adherence to clinical recommendations for identified health concerns such as Asthma, Diabetes, Hypertension and other chronic diseases. C. Community Outreach & Advocacy     1)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.     2)Share information and resources, collaborate on initiatives and provide education to referral sources and community agencies in order to coordinate access to services.     3)Collect and organize information to be used for current services and future community health education and outreach activities. D. Program & Care Team Operations     1)Participate in care team huddles to understand and proactively respond to the needs of the patient population.     2)In collaboration with the clinical team, identify, consolidate and manage a high-risk patient registry.     3)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.

Knowledge, Skills & Abilities Required:•Good communication skills. Ability to work as a team member. Competent computer keyboard, laptop manuvering, 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 • n/a

Physicial Requirements and Working Conditions: Spanish-speaking a plus Able to sustain full time, 40 hrs/week schedule Able to navigate city driving/find specific residences Hold 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. Familiarity with and experience working in Chicago’s South and Southwest communities (resident of Southside communities preferred). Passion for and dedication to working with community members Excellent phone mannerisms Ability to effectively engage conversation, motivate and engage patients to participate in our program, and speak to all types of patients, particularly seniors. May need to flex daytime hours to stretch to 8pm M-F and possibly Saturday if needed to reach pts after work hours. If position has direct patient care or direct patient contact the following lifting requirement supersedes any previous lifting requirement effective 06/01/2015. Ability to lift up to 35 pounds without assistance. For patient lifts of over 35 pounds, or when patient is unable to assist with the lift, patient handling equipment is expected to be used, with at least one other associate, when available. Unique patient lifting/movement situations will be assessed on a case-by-case basis.

Addendum: updated old jd for new APP position

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.