1. Functional responsibilities.

• Facilitates and is the Liaison for patients between community and clinic services being sought. Assist in accessing referrals to community resources, including housing, food, clothing, school programs, vocational opportunities or services, and relevant health services.

• Assists patients in developing natural resources and ensures that appointments are made, being the support network.

• Assist individuals with application, enrollment, and renewal processes for Medicaid, CHIP, and other benefit programs.

• Coordinates and monitors comprehensive tracking of patients. Follow up through a telephone call or home visit to ensure the new user can receive the correct services offered by the clinic.

• Attends and participates in training, staffing, calendar planning, and other agency meetings as appropriate and designated by the supervisor.

• Attends specialized skill-building training.

• Submits monthly reports.

• Performs other tasks as assigned by supervisor.

• Reports to the Outreach Director as approved by the chain of command.

• Screens patients for the eligibility status in qualifying for assistance programs.

• Notifies the necessary staff members of each patient’s eligibility status.

• Refers patients to appropriate sources for assistance programs as necessary.

• Demonstrating flexibility, enthusiasm, and willingness to cooperate while working with others in assigned inter-professional care teams to support PCMH programmatic activities.

• Participate in population management activities as directed.

• Assist the care team by helping to measure quality, identify, refine, and implement practice improvements that support the medical home, and assist in performance evaluation and quality improvement.

• Apply the principles of comprehensive, community-based, patient-centered, developmentally appropriate, and culturally and linguistically sensitive care.

2. Answer any questions on the eligibility status of patients.

Specific responsibilities:

• Identification and Engagement

  • Initial contact with the possible old and new users.

  • Gather data about the entire family so we can direct family members to the right clinic for the service needed. The following will need to be assessed at every new contact:

    • Completion of an intake

    • Information sharing

    • Direction and guidance to appreciate provider

    • Build up patient volume and follow up

• Accessing Resources and Linking

  • Collaborates and partners with the professional resource network of providers.

  • Partners with and refers to other resources and volunteer organizations in the community for alternatives and support.

• Service Implementation

  • Directs medical questions to appropriate information by printed data or providers in that medical field.

  • Conferences with service providers.

  • Maintains flexible schedule.

  • Effectively communicates with service providers and patients.

  • Co-coordinates and prevents duplication of services.

  • Coordinates activities with the Outreach department.

• Maintains systematic records

  • Documents all client contacts complete and submits documentation as appropriate; maintains comprehensive client files.

  • Number of referrals and contacts.

  • Name and Number of agencies and providers that link services.

  • Number of presentations to schools and businesses.

  • Number of patients who receive case management and clinic services.

  • Provides information to each patient about sliding fees, knowledge of applied discounts, and what to bring to the first visit.

• Advocacy

  • Promotes and interprets to the participant, community health care partners, and peers the role of the Esperanza clinic and its services, along with brief case management.

  • Advocates on behalf of Esperanza to promote prevention and wellness.

  • Advocates for the patient and clinic, identifying gaps in the system.

  • Participates in social action for program refinement and ongoing education.

  • Reinforces Mission, Core, and Value statement

• Evaluation of Outcomes

  • Works in coordination with the Success by 6 and Outreach Promotora coordinator, helping plan, process, and follow up on patient satisfaction, goal attainment, and efficiency.

  • Decreases fragmentation and duplication in the system.

  • Identifies trends and factors contributing to successful service delivery.

  • Improves accessibility to the system

  • Promotes cost containment.

• Promoting Health

  • Participates in conferences regarding case management.

  • Promotes ongoing prevention.

  • Identifies opportunities and resources to develop services.

• Professional Accountability

  • Within the limits of the profession, acts to ensure the delivery of quality, cost-effective, equitable, and timely services in a confidential manner.

  • Provides the appropriate documentation for information gathered and actions taken to promote communication

  • Represents Esperanza Clinic to internal and external audiences.

  • Promotes a positive image.

  • Identifies opportunities and initiatives for improving service quality.

3. Maintains professional courtesy at all times.

4. Performs all other related duties as assigned.