**Req Number** 177477

Job Description

Coordinates and participates in activities related to Care Management services to family members and caregivers. Health Home Plus is an intensive Health Home care management service established for defined populations with SMI (severe mental illness) who are enrolled in HHSA.

Job Responsibility

+ Utilizes patient-centered motivational interviewing techniques to build rapport and help patients improve their health.
+ Supports the primary care team by providing panel management to decrease the number of patients lost to care, non-compliant in follow up care or disconnected from primary care. Participates in the development, maintenance, and adjustment of individualized care plans for high-risk patients that address both medical and social barriers to accessing care.
+ Acts as a professional liaison between hospitals, primary care providers, specialists, and community resources on behalf of patients to ensure...