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Description:

Serves as a bridge between the health system and patients, particularly patients with Medicare and/or Medicaid and patients with identified social needs. Works to promote, maintain, and improve health and well-being through informal support and counseling to their patients. Uses culturally appropriate outreach, support, and navigation to help patients access health care and address identified social needs. Plays a key role in building individual capacity by increasing patient’s health knowledge and self-sufficiency through a range of activities such as health education, goal setting, motivational interviewing, and advocacy. Works collaboratively with other healthcare team and community-based providers to improve patient health outcomes and reduce racial, ethnic, and economic disparities in those outcomes.

ESSENTIAL FUNCTIONS

1. Knows, understa...