Critical Tasks

• Provides coordination for one‐on‐one primary care services and behavioral health services for clients
• Establishes relationship bonds that encourage clients to live and work well
• Coordinates primary care with healthcare providers and other professionals as necessary to promote whole person care.
• Observes and removes barriers to accessing and actively participating in health care services for clients (such as transportation, insurance, health literacy, etc.)
• Coordinates and provides referral services to address social determinants of health that may be impacting member health outcomes and obtains pertinent resource materials for clients, conducts SDOH screenings as necessary.
• Coordinates primary care services for preventive care such as well/annual visits and wellness screenings for cholesterol, diabetes, heart disease, asthma, and cancer
• Coordinates healthcare and supportive services to support the member in management of chronic conditions such; diabetes, hypertension, smoking cessation, weight loss and other healthy living support care. Supports the primary care provider, treatment team and the member in closing Care Gaps within HEDIS measures
• Coordinates primary care services for diagnosis, primary care treatment plans and follow‐up with health care providers
• Coordinates and connects service interventions on behalf of clients and provides non‐clinical support services such as client advocacy and client education support
• Communicates with primary care and other healthcare providers regarding client medical and mental health conditions and strategies for recovery and informs clients of proposed treatment plans
• Works with the member and healthcare providers to develop health and wellness treatment goals for the Integrated Service Plan, using SMART Goals
• Coordinates with the treating team to gather and share member health information under an integrated care model to improve member healthcare outcomes (such as population health data, Health Information Exchange, hospital alerts, EMR, team clinical staffing’s, etc.)
• Transport or coordinates transportation for clients for medical appointments
• Participates in site based staff meetings
• Will inquire about the client’s cultural preferences and how that impacts health and wellness needs.
• Assists in coordinating primary care or other supportive services with appropriate JFCS staff or external parties to ensure the clients whole health is addressed.
• This position will communicate with Community Relations and Patient Advocate, Care Manager, Health Promotion or other staff as necessary to ensure coordination and follow-through for clients needing primary care services.
• Performs other duties as assigned

Key Performance Indicators

• Maintains positive professional relationships with primary care providers, staff and clients
• Plans, arranges and prioritizes healthcare activities on behalf of clients
• Remains current and knowledgeable about primary care and community health services provided by JFCS and is knowledgeable on how to refer clients to external resources when necessary
• Develops Integrated Health Navigator Goals for the members treatment plan in collaboration with treating team, using SMART goals
• Remains current on preferred primary care practices used by providers and primary care staff

Metrics

• Is timely in coordinating services on behalf of clients
• Presents accurate documentation of behalf of clients related to eligibility and insurance
• Communicates with primary care providers and relays accurate information to clients
• Is cognizant of deadlines for the provision of services and communicates and ensures client awareness of those in receiving services
• Remains aware of any service changes that may affect client’s treatment plan or reception of primary care services

Qualifications

-Bachelor’s Degree, and/or Associate Degree or High School Diploma with one year of health care or behavioral health experience. Education must be from an accredited organization and verified by 3rd party.

-Computer proficiency

-Good communications skills orally and in writing

-Level 1 fingerprint clearance card from AZ DPS without any restrictions

-AZ Driver’s License

-AZ Auto Insurance

-MVR report that meets JFCS policy standards

-Must be able to perform the essential functions of the job including prolonged sitting and in certain positions driving, lifting 20lbs, walking, standing and executing dexterity with a keyboard or smart pad.