Assist participants in their homes or community setting. Communicates to participants the
purposes of the program and the impact it may have on their wellbeing. Helps participants.
identify socio-economic issues that affect their overall health and develop health/social.
management plans and goals.
Documents all participant encounters and contracts made on behalf of participant; completes and
submits monthly reports timely; maintains comprehensive electronic participant files, which
include participant notes, release of information, assessments and other documents acquired on
behalf of the participant. Documents activities, service plans, and outcomes achieved by
participant in an effective manner.
Educates the participant on the proper use of the Emergency Room and provides information for
alternatives. Coaches participant in effective management of their chronic health conditions and
self-care. Assists participant in understanding care plans and instructions. Motivates participants
to be active and engaged participants in their health and overall wellbeing.
Assists participant in accessing and overcoming barriers to obtaining needed medical care and/or
social services
Provides support and advocacy during medical visits when necessary to assure participants
medical needs and referrals required are being conveyed. Follows up with both participant and
providers regarding health/social service plans.
Continuously expands knowledge and understanding of community resources and services.
Facilitates participant access to community resources, including locating housing, food, clothing,
and providers to teach life skills, and relevant mental health services. Assists participant in
utilizing community services, including scheduling appointments.
Facilitates communication and coordinate services between providers and the participant.
Disclaimer: This description reflects managements assignment of essential functions, it does not
proscribe or restrict the tasks that may be assigned; thus, may be subject to change Revised 9/2019
Coordinates and monitors services, including comprehensive tracking of participants compliance
in relation to care plan objectives.
Works collaboratively and effectively within a team. Establishes positive, supportive
relationships with participants and provides feedback to another member of the team. Builds and
maintains positive working relationships with the participant, providers, Support Coordinators,
agency representatives, Leadership, and office staff, from diverse cultural and socio-economic
backgrounds. Works to reduce cultural and social-economic barriers between participants and
institutions.
Travels extensively to participant homes, community locations, various agencies, and other
outreach destinations.
Educates members, caregivers and service providers regarding the roles and responsibilities of
each party, assuring that issues are addressed as documented.
Serves as a liaison and key resource between Participant and DAAA staff involving utilization
management, case management, and general medical issues.
Monitors participant progress in relation to goals and objectives listed in the plan of care.
Maintains participant confidentiality
Participates in training, supervisory meetings, in-services, and continuing education opportunities