Community Health Advocate-Population Health

Company Description

At Shore Medical Group, you can learn, grow and make a lasting impact on patients and families. You’ll experience the support of a collaborative work environment and a sense of collegiality unlike any other. Our comprehensive system has many locations and practice options to choose from throughout the beautiful Eastern Shore of Maryland.

General Summary

The Community Health Advocate will be responsible for helping patients and their families to adopt healthy behaviors and navigate /access community resources. As a priority, will actively promote, maintain, and improve the health of patients and their family by providing services such as blood pressure screening and completing social need assessments. Supports medical providers through an integrated approach to care management and community outreach by providing social support and informal counseling, and advocating for individuals and their community health needs. Community outreach, such as home visits and health screenings, may be required.

Principal Responsibilities And Tasks

The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. These are not to be construed as an exhaustive list of all job duties performed by personnel so classified.

• Conducts intake interviews with patients, including enrolling and/or referring patients to healthcare provider.
• Records patient care management information in the EMR (training provided) and other software no later than 24 hours after patient contact.
• Responsible for establishing trusting relationships with patients and their families while providing general support and encouragement.
• Performs MA duties as assigned.
• Provides ongoing follow-up with patients via phone calls, home visits and visits to other settings.
• Serves as coordinator to evaluate patient/family status, ensuring that provided information, and reports clearly describe progress.
• Attends regular staff meetings, trainings, and other meetings as requested.
• Works closely with medical provider to help ensure that patients have comprehensive and coordinated care. Follow-up with patients should be continuous from initial identification through closure.
• Acts as a patient advocate and liaison between the patient/family and community service agencies (i.e. Healthcare providers, support groups, etc.)
• Manages assigned caseload of patients.
• Other duties as assigned.
• Provides referrals for services to community agencies as appropriate. Be knowledgeable about community resources appropriate to needs of patients/families.
• Responsible for providing consistent communication to the Care Management Team.

Qualifications

Education and Experience

• High School diploma or equivalent required.
• One clinical experience or successful completion of a formal medical assistant training program required.
• Experience working in a multi-cultural community-based setting preferred.
• Certification as a Medical Assistant or Certified Nursing Assistant preferred.
• Current BLS certification or obtained prior to providing direct patient care is required.

IV. Knowledge, Skills And Abilities

• Knowledge of some medical terminology.
• Ability and willingness to provide emotional support, encouragement and motivation to patients.
• Basic computer skills.
• Written and oral fluency in English required.
• Good communication skills, such as listening well, and using language appropriately.