- Play an active role in patient registration and enrollment, including organizing community engagement and outbound calls to patients.
- Conduct outreach (virtually and in-person) to patients scheduled for appointments and complete initial intake.
- Engage with a panel of assigned patients to provide care navigation, appointment logistics, prescription drug support, lab support, referral coordination, care plan adherence, and resource sharing.
- Assess for social determinants of health (SDOH) needs and enroll patients in SDOH programs, including care planning development, referral to community resources, coaching, and graduation planning.
- Collaborate with a multidisciplinary care team to contribute to care plans, triage requests, and solve complex patient needs.
- Participate in community events to support patient activation and trust-building, including relationship-building with key contacts, facilitating group education sessions, and liaising with community organizations.
- Provide culturally and linguistically appropriate health education and information.
- Assist with federal and state support program enrollment, appointment scheduling, referrals, and promoting continuity of care.
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