Job Summary

This role is a core member of the integrated care team.  Takes lead in identifying and developing relationships with key community stakeholders including but not limited to, housing authorities, food banks, financial aid entities, clothing, transportation, employment, education, and community integration resources. Works closely with the interdisciplinary care team to provide guidance and advise on appropriate community linkages for members, with the goal of improving overall health and wellbeing through meeting SDoH needs, as measured by key performance indicators that include increased adherence to treatment plan compliance, decreased preventable medical/psychiatric events, (e.g., emergency room utilization, hospital admissions, and hospital readmissions), increased community integration, successful housing placements and member retention.  Manages the allocation of financial assistance available through the Member Fund based on established guidelines and eligibility criteria. Promotes the mission, vision and values of AbsoluteCare in all member and multidisciplinary team interactions.

Duties and Responsibilities

• Identify and develop relationships with key community partners and stakeholders, including hosting and/or participating in meetings in the community.
• Maintain relationships with community partners to facilitate timely access and engagement with services.
• Support development and operationalization of SDoH initiatives including but not limited to “Food is Medicine,” food/clothing drives, establishing on-site pantries and closets.
• Participate in interdisciplinary team meetings as a subject matter expert (SME) in SDoH and local community resources, with key expertise in affordable housing.
• Establish relationships, and maintain regular contact with property managers, landlords, and other affordable housing resources, in-person and/or telephonically.
• Maintain up to date documentation in the electronic health record, including measures to track progress required to successfully complete resource/SDoH-related care plan goals as identified by the primary care manager.
• Perform on-site visits to landlords and members to observe and document living environment to ensure safe residential settings and property, as needed.
• Advocate on behalf of members for property rights, maintenance, and services as listed in rental or property lease agreements or contracts.
• Maintain database of community services and resources, assist internal staff in learning and accessing database to link members to community resources.
• Directly support members, when necessary, through in-person or telephonic support.
• Actively participate in all required individual, team, and community meetings.
• Maintain the allocation and tracking of the Member Fund, per Company guidelines and eligibility criteria.
• Represent AbsoluteCare professionally to external partners through excellent communication skills, positive attitude, and timely follow-up on agreed upon activities.

Minimum Qualifications

• Bachelor’s degree in a health care, behavioral health, or social work field; Master’s level preferred.
• High School Diploma or Equivalent Required.
• 3+ years of experience in serving the needs of complex populations in a health care or social service setting, working directly with members in an office or community-based setting.
• Experience building strong relationships with community-based organizations.
• Excellent computer skills including Microsoft Office Suite (Outlook, Excel, PowerPoint, Word) and electronic medical record documentation required.
• Excellent written and oral communication skills to interact with internal and external stakeholders.
• Ability to work independently, exercise good judgment, and creatively problem solve.
• Valid Driver’s License and proof of insurance in state of employment.
• Access and use of personal vehicle.

Working conditions

This job operates in a professional office utilizing general office equipment and in a variety of community settings including member homes, medical offices, community locations and other non-traditional sites.  This role requires the use of a personal vehicle for community visits.

Physical requirements

• Ability to communicate clearly and exchange accurate information constantly.
• Ability to remain stationary for long periods of time.

• Access to and Ability to use personal vehicle to travel within the local community.

• Operates computer, keyboard, copy and fax machine, phone, and other general office equipment.

• Ability to occasionally move objects up to 30 lbs.

Direct reports

None.