Essential Functions Actively engages a population of medically vulnerable or chronically ill patients in their care, assisting them through the process of working towards better health by providing support, encouragement, and education. Communicates with patients (and caregivers) in person, in groups, by telephone and via electronic means. Monitors patient-reported biometrics, medication adherence, reported challenges/barriers and promptly connects the patient with the appropriate resources, and/or notifies the patient's care team for additional follow-up. Advocates and facilitates referrals to gain access to services and resources for patients/teammates, including assistance programs, community based services and mental health support. Assists providers' offices with member specific missed appointments through outreach and scheduling. Provides customized, evidence-based patient education in a variety of areas including but not limited to weight management/exercise, tobacco cessation, stress reduction and chronic disease self-management. Advocates for help for those who frequently access inappropriate levels of care (e.g., visiting the emergency department for conditions that can be better treated by a primary care physician). Physical Requirements Work may occur in a variety of settings, including office, clinic, school, or other community setting. Requires walking, standing, sitting, lifting, reaching, bending, pushing and pulling. Must be able to lift and support the weight of 50 pounds in handling equipment and supplies. Must have intact sense of sight, hearing, smell, touch and finger dexterity. Must be able to move about the medical center and to travel to various clinical and community locations. Education, Experience and Certifications High School diploma or equivalent required.