Want to be a part of an amazing organization? An organization that makes a difference in the lives of individuals each and every day?

Monroe Plan for Medical Care is a not-for-profit health care services organization that has been meeting the needs of our members in the Greater Buffalo, Rochester, Syracuse, Albany and Binghamton Regions for the past 50 years. Monroe Plan provides health home services and other critical health care services to individuals covered by Medicaid, Child Health Plus and the Essential Plan.

Following our mission and vision to improve the health status of individuals and families, Monroe Plan's innovative clinical care management programs are structured to meet the unique needs of members, providers, health care organizations and the communities we serve. Monroe Plan has consistently been recognized as a national leader in the "safety net" area, with a proven track record of improving health outcomes and reducing disparities by supporting a health care delivery system that ensures the availability of high quality medical care for all.

Community Health Outreach Representative
Grade 206
This position requires travel throughout Monroe County and some limited travel throughout neighboring counties


Position Summary
Provide community and home based outreach to identify barriers to care, link to appropriate community resources, and facilitate referral to other services in order to reduce health disparities and improve health care outcomes.
 

ESSENTIAL JOB DUTIES/FUNCTIONS

% of Time	Essential Function
50	Interventions: - Collect information to identify needs or barriers to care experienced by members - Conduct ongoing telephonic/written/in home or practice based outreach to members to facilitate appropriate utilization of the health care system and assist members in establishing and maintaining an effective relationship with a Primary Care Provider (PCP) or other providers.         - Facilitate/assist with appropriate linkage to community services         - Refer members to appropriate case manager to have medical or behavioral health questions addressed  - Travel to members’ homes, providers’ offices, etc. as needed to provide services. - Utilize the empowerment model (self-management support interventions) to promote self-advocacy through support and encouragement of the member. - Reduce and /or report barriers to linkage of members to appropriate mental health, health and social service, chemical dependency or other community agencies. - Provide pre-printed Monroe Plan specified education/ information and health advice according to Monroe Plan protocols. - Promote healthy living by identifying potential opportunities to encourage healthy lifestyle choices and refer to community support services. - Document member and practice communication in the appropriate Monroe Plan software on a timely basis. - Identify, address and decrease barriers related to Gaps in Care. - Provide culturally competent care based on member assessment and identified cultural needs. - Advocate for the member to assure access and service delivery across the continuum of care and community resources.
30	Under the direction of the Case Manager on a case specific basis - Using established tools relay information to the case manager for assessment and referral. - Encourage member adherence to provider advice and contact case manager with questions or concerns related to adherence to provider plan of care. - Use established self-management support tools to monitor the member’s level of self- management over time by collecting information and referring to case manager for assessment.
10	Identification - Receive referrals of members in need of services from internal/external sources
10	Communication - Collaborate with other members of Clinical Services staff related to member needs, barriers to care and outcome enhancement strategies. - Prepare for and participate in case review meetings with the case manager to share cases, discoveries, concerns and collaborate in the development of plans of action. - Actively participate in appropriate practice-support forums and appropriate patient care team meetings as requested. - Share updated information related to appropriate community resources for the Resource Grid and serve as an information source for providers and other members of the health care team. - Provide feedback to providers regarding the progress made and barriers encountered by their patients.

Total must equal 100% - essential functions should be completed at least 10% of the time

 

OTHER FUNCTIONS AND RESPONSIBILITIES

- Provide program information to members and providers, and other organizations as requested to introduce and support program participation.
- Collect information for reporting purposes as requested.
- Provide input relating to changes that may enhance the program.
- Serve as a resource for Clinical Services and Monroe Plan staff and to providers regarding community resources for their patients.
- Serve as a liaison to health and social service agencies involved in the care and support of members.
- Actively participate in appropriate practice-support forums and appropriate patient care team meetings as requested.
- Participate effectively as a Team member within the Clinical Services Department and any other Monroe Plan team:
- Foster a positive working relationship with members, providers and Monroe Plan staff.
- Work effectively with others to coordinate member and access care support services.
- Support team members for cross coverage as work load dictates.
- Participate in community activities to promote health and public awareness using Monroe Plan specified materials.
- Attend and participate in in-service trainings/meetings provided by Monroe Plan Clinical Services.
- Adhere to Monroe Plan professional boundaries and protocols.
- Outreach Field Representatives will be required to drive to practice locations and member’s homes. Outreach Preventive Representatives will not be required to drive.
- Performs other duties as assigned.

Position Limitations:

- Functions under the general direction of a licensed professional for Medical and/or Behavioral health based cases.
- Cannot perform any tasks which are governed by license or registration (i.e. cannot answer questions or make recommendations RE diagnosis, medications or treatment).
- Cannot transport active Monroe Plan members at any time.
- Cannot perform hands on care.

MINIMUM REQUIREMENTS/LICENSES/CERTIFICATIONS

- High school education or equivalent.
- Two years community outreach experience or equivalent.
- Demonstrated ability to respect individual/family diversity and maintain confidentiality.
- Demonstrated ability to work as a team member.
- Knowledge of and ability to work collaboratively with providers and county/community health and human services.
- Ability to demonstrate excellent communication skills both oral and written as well as strong interpersonal skills.
- Ability to work independently.
- Strong organizational skills.
- Computer literate.
- Qualified candidates for the Field Outreach Representative will need a NYS driver’s license and to own or have access to reliable transportation that enables them to fulfill travel requirements of the job including but not limited to, daily visits to members’ homes. 

PREFERRED QUALIFICATIONS

- Bilingual Candidate Preferred
- Previous experience in Behavioral Health to support members with mental health or chemical dependency inpatient hospitalizations in obtaining outpatient follow up care
- Previous medical experience such as in a doctor's office, hospital or other medical setting

 

 

PHI MINIMUM NECESSARY USE: This staff position PHI access will be determined based on Minimum Necessary standards. The Minimum Necessary Grid can be found on the Human Resources and Compliance Web pages.

 

 

 

This job description is only a summary of the typical functions of the job, not an exhaustive or comprehensive list of all possible job responsibilities, tasks and duties. Additional responsibilities, tasks and duties may be assigned as necessary.

Monroe Plan for Medical Care is an Equal Opportunity Employer.