Job Description:

Supports and promotes clinical quality of care programs and acts as liaison between the clinic, patients and Rescue Mission staff to ensure that Enhanced Care Management (ECM) objectives are achieved. Provides education to patients and their families regarding community resources and chronic health issues with the support of clinic management and medical providers. Develops and implements communication systems with Orange County Rescue Mission along with outbound patient contact programs for improvement of patient compliance and quality measures.


  1. Associates degree or equivalent education and experience that includes 2-5 years directly-related work experience specializing in a community health setting and working with diverse populations.
  2. Bi-lingual in Spanish and English.
  3. Must be able to function as a healthcare liaison between vulnerable communities and the formal healthcare system to improve health awareness and well-being.
  4. Must be familiar with providing specialized counseling groups or classes.
  5. Ability to receive instruction from supervisor.
  6. Proficiency with Windows, Microsoft Office (Word, Excel, Outlook, PowerPoint, Internet Explorer.) and EHR systems.
  7. Ability to work within a flexible and changing schedule.
  8. Treat people with dignity, respect, compassion and integrity at all times.
  9. A pleasant personality to people you are speaking to on the telephone, visitors, and company personnel.
  10. The ability to act and think promptly and professionally.
  11. Demonstrated “detailed approach” to organization.
  12. Excellent verbal and written communication skills.
  13. Legible writing skills.
  14. Basic typing (40 wpm.)
  15. Self-motivated and flexible.
  16. Maintains an acceptable driving record (in accordance with our insurance carrier, less than 2 DMV points on driving record.)
  17. Ability to recognize and maintain confidentiality of information as appropriate.
  18. Regular and timely attendance

Job Responsibilities & Duties

  1. Establish collaborative and supportive relationships with Physicians, staff, patients and interdisciplinary teams acting as a patient advocate and liaison to support the patient’s efforts to reach their healthcare goals.
  2. Work with Health Center staff and other community resources to become knowledgeable about available services that may be helpful to patients.
  3. Identify and manage patient risk and need through whole person care approaches and addressing social determinants of health
  4. Help patients to understand recommended follow-up of abnormal screening exams, treatment referrals and general preventive behaviors.
  5. Assess the patient’s ability to navigate through the healthcare system and identify possible barriers to diagnosis and treatment.
  6. Act as lead for Enhanced Care Management program ensuring metrics and goals are met and reporting is submitted on time.
  7. Make entries into patient’s electronic health records to document outreach efforts and patient contact.
  8. Help ensure that VOH patients are attending scheduled visits and following up and rescheduling as needed.
  9. Works closely with Rescue Mission program staff to gather pertinent patient data for ECM reporting.
  10. Obtain and enter into electronic health records for testing and consult notes for appointments completed with providers outside the clinic to document patient compliance.
  11. Follow-up with patient on results as directed by the Provider.
  12. Link patients with other social services and community partners to support lifestyle changes.
  13. Provide positive problem solving resolutions to patient’s needs/demands.
  14. Schedules visits with patients on site and provides one-on-one education.
  15. Schedules patients for additional education classes and connects them to community resources and educational tools.
  16. Acquire Covered California certification and assist patients with any insurance challenges and needs.
  17. Assists with scheduling and facilitating patient education workshops.
  18. Perform other duties as assigned.
  19. Submits reports on all activities and outcomes to direct supervisor.
  20. Updates and enlarges HFHC’s image in the community
  21. Maintains a clean, safe and unobstructed workplace.

These duties are not exclusive and with consideration of the job requirements and employee skills, this job description can be added to or taken away from at the discretion of the employee’s immediate supervisor.