Job DescriptionThis is a grant based program with a duration of 3 years.Focused on minority patients with diabetes1. Assessment:* Identify and assess high risk patients with chronic disease, complex medical, and psychosocial needs referred to the CARE Center* Complete a thorough assessment with patient's history including medical, physical, social, emotional, psychological and financial needs that will assist the care team in developing a care plan* Identifies barrier to health care, to include Social Determinant of Health (SDoH), and medical that focuses on the prevention of readmissions.2. Care coordination:* Provide telephonic guidance, advice and support to pati