Conduct outreach activities through various methods and engage individuals with chronic medical conditions, mental health issues, and/or substance use disorders, often o-occurring. 

Essential Accountabilities: Conduct outreach activities through various methods and engage individuals with chronic medical conditions, mental health issues, and/or substance use disorders, often co-occurring. Conduct initial and ongoing comprehensive assessments to determine strengths and identified needs. Prepare and revise care plans to reflect client needs and personal goals with a focus on maintaining health and wellness. Maintain contact with clients at least monthly, providing telephonic as well as face to face outreach, engagement, and comprehensive service planning in the field. Advocate for and support clients to ensure access to resources necessary to support wellness/self-management and decrease frequency of emergency room visits and inpatient hospital admissions. Monitor and coordinate all care for clients, including access and maintenance of medical insurance, linkage to treatment providers and community resources. Collaborate with community providers as part of a multi-disciplinary team to ensure goal-directed care planning. Conduct crisis intervention when needed and follow up accordingly. Maintain detailed, timely, and accurate record keeping in an electronic medical record. Coordinate with supervisor, office manager, and health home outreach team in a timely manner to ensure accurate caseload status (including enrollments, closures, and screen outs). Complete all required monthly documentation as required to ensure continuity of engaged clients’ medical insurance and to ensure appropriate and accurate billing. Work as part of a care management team, attend and participate in weekly team meetings to provide feedback and share resource information relating to client needs, issues, and concerns. Be responsible for reporting/coordinating daily office and field schedules with other members of the team and supervisor, as well as documenting schedule for the office manager. Offer resources and serve as a consultant to all team members on medical/psychosocial/substance use issues as well as social service needs. Attend periodic trainings to enhance skill level and learn about wellness self-management and best practice skills. Participate in weekly individual supervision to address concerns/issues and improve skill development. Be responsible for agency vehicles, including upkeep, documentation, and gas card when assigned. Be responsible for agency cell phone, laptop, and associated items. Follow program guidelines as outlined in the personnel manual. Report to the program administration any issues and/or concerns on a regular/as needed basis while working in the field. I acknowledge that the above job description has been reviewed with me and that I am able to perform the necessary functions of the above job description.