Job Title

REPORTS TO: Director of Primary Care Behavioral HealthEDUCATION & EXPERIENCE: Master's degree in social work, public health or administration, or any related field, or bachelor's degree with commensurate experience in these fieldsSKILLS: Basic understanding of chronic care management and primary care systems Ability to navigate health care systems General knowledge of chronic health care conditions and needs Ability to communicate across disciplines Familiarity with coordinating support services for patients Excellent written & verbal communications Bilingual (English/Spanish) ability is preferred and reflected in compensationPRIMARY DUTIES:Implement and support care management for patients with medical and behavioral disorders.Coordinate with primary care teams, and collaborate with community partners to address unmet needs for at-risk patients.Provide problem-solving assistance and decision-support to primary care teams implementing care management.Perform advanced care management tasks including pre-visit planning, providing patient education, monitoring registries and supporting patient self-managementProvide care coordination services to address short- and long-term medical and behavioral health treatment goalsCommunicate with physician and care team members about relevant patient needs or changesOTHER DUTIES:Other duties as assigned by supervisorPHYSICAL AND MENTAL REQUIREMENTS:Visual and auditory accuracyShift length - 8 hoursIndoor settingFrequent use of computerLong periods of sittingFrequent use of telephoneContinuous repetitive grasping and manipulation of both handsContinuous conversational communicationOccasional reaching, walking, squatting, bending, kneeling, twisting and climbingOccasionally carrying, lifting, pushing and pulling of up to 25 lbs.Occasionally working in confined, noisy, dusty areasPeriodic use of personal transportationUnderstand/carry out simple/detailed, oral/written instructions with retentionRead and interpret detailed specifications