Outreach and Patient Engagement

• Identify and engage patients at risk for or are diagnosed with cardiovascular disease (CVD), focusing on moderate-risk individuals.
• Provide culturally responsive education on cardiovascular health, risk reduction, self-management strategies and program benefits. 
• Assist patients with appointment scheduling, reminders, and transportation arrangements.
• Conduct proactive outreach to patients who miss visits or are overdue for follow-up to reinforce care plans and reduce missed appointments. 
• Build trusting, ongoing relationships with patients, acting as a consistent point of contact to support adherence to care plans and promote self-management and adherence.

Health Education and Coaching

• Provide health coaching on lifestyle modifications, including healthy eating, physical activity, stress management, smoking cessation, and medication adherence.
• Support patients in using digital health tools (e.g., home blood pressure monitors, smartphone-enabled ECGs, remote patient monitoring devices).
• Use motivational interviewing and teach-back methods to reinforce provider and care team guidance and instructions and confirm patient understanding.
• Provide ongoing encouragement and support for sustainable lifestyle changes.
• Deliver linguistically and culturally tailored materials to ensure accessibility and patient understanding.

Referral and Resource Coordination

• Conduct Social Determinants of Health (SDOH) screenings using standardized tools (e.g., PRAPARE).
• Document findings in the electronic health record (eClinicalWorks) to inform care planning and referral processes.
• Refer patients to enabling services and community-based resources (e.g., food assistance, housing, transportation, legal aid).
• Collaborate with community-based organizations and agencies to establish seamless connections between patients and SDOH resources.
• Provide follow-up to ensure referred services are accessed, using a bi-directional referral system to support closed-loop referrals and confirm completion of services.

Care Team Collaboration

• Actively participate in care coordination huddles with providers, Case Managers, Pharmacists, Nutritionists, and Behavioral Health staff.
• Communicate patient progress, barriers, and social needs with the care team, ensuring coordinated, whole-person care.
• Serve as a bridge between patients, the cardiovascular care team, and community partners.

Documentation and Quality Improvement

• Maintain timely, accurate documentation in eClinicalWorks, including encounters, referrals, and follow-up activities.
• Assist in chart reviews for quality assurance purposes as requested. 
• Assist with data collection and reporting requirements for program evaluation and quality improvement initiatives.
• Participate in QA/PI initiatives, including Plan-Do-Study-Act (PDSA) cycles and staff trainings.
• Support dissemination of program outcomes and lessons learned through patient stories and feedback.
• Perform other duties as assigned to ensure the success of the Center for Justice in Cardiovascular Health. 

To perform successfully, the individual must be able to perform the essential duties satisfactorily. The requirements below are representative of the knowledge, skill and ability required.

• Strong understanding of cultural diversity with a commitment to health equity.
• Bilingual proficiency in English/Spanish strongly preferred.
• Knowledge of cardiovascular health, chronic disease prevention, and social drivers of health preferred. 
• Effective communication, problem-solving, and organizational skills.
• Proficiency with Microsoft Office, Outlook, and EHR systems (eClinicalWorks preferred).
• Ability to collaborate effectively with patients, families, providers, and community agencies.
• Decision-making, priority setting, and delegation abilities. 
• In-depth knowledge of community services and resources.
• Ability to work independently or as part of a team, meet strict deadlines, and manage group activities.
• Strong interpersonal skills with a customer-focused approach.
• Commitment to maintaining confidentiality. 
• Willingness to travel between sites as needed.
• Ability to learn and apply trauma-informed care principles.
• Skilled at interacting with healthcare practitioners, interdisciplinary teams, community agencies, patients, and families with diverse opinions, values, and cultural backgrounds.

Education, Training and Experience

• High school diploma required; Bachelor’s degree in Public Health, Social Work, or related field preferred.
• Minimum of 2 years of experience in a health care, public health, or community-based setting.