Job SummaryWorks within the community providing outreach to patients with complex medical and social needs. Acts as a resource to assist patients in navigating the health care system.Job DutiesAssists in the outreach of patients identified as medically complex.Collaborates with the multidisciplinary team in the reinforcement of the care plan.Engages patients by way of home visit, hospital visit and accompanying patients to Providers appointments as needed.Facilitates adherence to treatment plan by early identification and resolution of gaps in care.Participates in multidisciplinary team conference in order to maximize the treatment plan.Provides reinforcement of the treatment plan under the direction of the Case Man