Chronic Disease Management Facilitation
Coordinate outreach and follow-up for patients with chronic disease needs, missed or overdue appointments, post-discharge follow-up needs, barriers to care, or noncompliance with chronic disease management expectations.
Support patients in understanding provider instructions, diagnoses, medications, prevention strategies, and recommended follow-up, as directed by the provider or care team.
Assist patients with scheduling and attending appointments as needed to improve visit attendance compliance and continuity of care.
Provide one-on-one or group health education related to chronic disease, prevention, medication adherence, and self-management support.
Chronic Disease Management Data Collection, Review & Reporting
Collect, maintain, and review CDM-related data using the EHR, approved tracking tools, and assigned population health platforms.
Identify patients through

EHR SDOH

screening data, chronic disease management reports, emergency department utilization patterns, insurance gaps, and other approved data sources.

Track patient progress, outreach attempts, referrals, follow-up completion, and outcomes related to care plan goals and CDM workflows.
Participate in quality review, assurance follow-up, interdisciplinary case reviews, huddles, and QI activities to evaluate trends, barriers, opportunities, and interventions.
Contribute concise, timely data updates for program reporting, leadership review, grant reporting, and performance improvement activities.
Substance Use Navigator (SUN) / LA Bridge Program
Serve as the Emergency Department SUN and primary liaison for substance use navigation activities, including screening coordination, brief interventions, MOUD warm handoffs, naloxone education, and referral coordination.
Coordinate follow-up and closed-loop referrals for patients identified with substance use needs, behavioral health needs, or related social service barriers.
Maintain SUN-related documentation and tracking requirements in accordance with approved workflows, HIPAA expectations, and program requirements.
Collect monthly MCIP data elements assigned to the SUN/LA Bridge Program role and prepare data for submission through the designated reporting process.
Social Drivers of Health, Resource Navigation & Community Linkages
Conduct standardized SDOH screenings, document findings, and connect patients to appropriate internal and external resources.
Coordinate referrals and closed-loop follow-up for needs such as food, housing, transportation, Medicaid, Marketplace insurance options, financial assistance, behavioral health, and primary care access.
Maintain a current community resource/referral list and build relationships with local nonprofits, food banks, housing agencies, behavioral health providers, and social service coalitions.
Support CHNA review, activities, community health education, community events, and other initiatives that improve population health and access to care.
Care Coordination, Documentation & Compliance
Accurately document patient interactions, service encounters, referrals, follow-up activity, and outcomes in the EHR and/or approved tracking systems.
Apply appropriate Medicaid and Medicare reimbursement codes for eligible services when directed by organizational policy and approved billing workflows.
Collaborate with providers, medical assistants, nursing, case management, social services, the social worker, the Executive Project Manager, Nursing Educator, and other interdisciplinary team members.
Maintain patient confidentiality and protect patient information in accordance with HIPAA and hospital policy.
Identify and report patient safety concerns, neglect, abuse, or other concerns through appropriate escalation pathways. Required Knowledge, Skills & Abilities
Understanding of SDOH, chronic disease management workflows, community resource navigation, and patient-centered outreach.
Strong oral and written communication skills with the ability to provide culturally responsive and trauma-informed engagement.
Excellent organization, time management, multitasking, documentation, and follow-up skills in a fast-paced clinical environment.
Ability to work independently while collaborating effectively with clinical, quality, social services, and community partners.
Computer literacy with proficiency in Windows, Microsoft applications, EHR documentation, and approved tracking/reporting tools.
Critical-thinking, problem-solving, relationship-building, and patient advocacy skills.

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