Overview

Job DescriptionJob DescriptionPOSITION SUMMARY: As a member of the integrated healthcare team, this role serves as a critical link between clinical services and community-based social support resources. The position is responsible for identifying patient needs across medical, behavioral health, dental, and financial or eligibility-related areas. The role includes screening patients for psychosocial needs and social determinants of health (SDoH), assessing results, and connecting individuals to appropriate resources. This individual develops and maintains referral networks, navigates community services, and coordinates care to ensure patients successfully access and follow through with recommended support.ESSENTIAL JOB FUNCTIONS:Complete screening tools and comprehensive assessments, including: Psychosocial assessmentsSocial Determinants of Health screeningsCollaborate with departments and staff to gather required patient documents and informationHelp patients obtain documents needed for: Financial supportContinuity of careHIPAA-compliant releases of informationWork with patients to identify programs and services within the organization and communityMake timely referrals to appropriate services to improve patient quality of lifeAssist patients with completing intake paperwork and ensure documentation is added to the chartMaintain patient privacy and confidentiality at all timesFor behavioral health patients: Assist with transportation needsHelp reduce no-show rates through reminders and confirmationsConduct comprehensive initial screenings for new behavioral health patientsEnsure urgent needs are addressed quicklyUse the current EHR system to: Document patient information accuratelyTrack referrals and follow-upEnsure action is taken within appropriate time framesPerform other duties as assignedEDUCATION:Bachelor's degree required in: Human ServicesSocial WorkPsychologyRelated fieldAssociate's degree in a related field may be considered with comparable experienceREQUIRED SKILLS:Knowledge of or ability to learn: Electronic Health Records (EHR)Patient engagement applicationsProficiency in Microsoft Office Suite or similar softwareStrong critical thinking skillsAbility to analyze complex informationStrong verbal and written communication skillsAbility to work effectively with individuals from diverse: Socioeconomic backgroundsCultural backgroundsIntellectual backgroundsAbility to work both independently and as part of a teamPREFERRED SKILLS:Previous experience in: Social servicesBehavioral health2-3 years of related experience preferredBilingual in Spanish preferredSUPERVISION:This position does not have any direct reports.PHYSICAL REQUIREMENTS:May require prolonged sittingSome bending, lifting, stooping, and stretchingNormal hearing and vision requiredEye-hand coordination and manual dexterity needed for office equipmentMay lift up to 35 poundsLIMITATIONS AND DISCLAIMER: The above job description is meant to describe the general nature and level of work being performed; it is not intended to be construed as an exhaustive list of all responsibilities, duties and skills required for the position. All job requirements are subject to possible modification to reasonably accommodate individuals with disabilities. Some requirements may exclude individuals who pose a direct threat or significant risk to the health and safety of themselves or other employees. This job description in no way states or implies that these are the only duties to be performed by the employee occupying this position. Employees will be required to follow any other job-related requirements and to perform other job-related duties requested by East Central District Health Department/Good Neighbor Community Health Center in compliance with Federal and State Laws. Requirements are representative of minimum levels of knowledge, skills and/or abilities. To perform this job successfully, the employee must possess the abilities or aptitudes to perform each duty proficientl