DUTIES AND RESPONSIBILITIES: * Conducts comprehensive assessments of the physical and social environments of patients in order to determine practical plans for eliminating barriers to care and increasing self-efficacy to manage chronic conditions. * Assists other health care professionals in providing health care and treatment. * Connects patients to resources and services such as transportation, health insurance coverage, prescription assistance, SSI, Black Lung benefits, SNAP benefits, etc. and acts as an advocate on their behalf. * Provides navigation services, including going with patients to social service and medical appointments, if needed. * Makes home visits to patients with chronic disease. * Assists patients in filling out medical forms. * Maintains records on all cases regarding visits, interviews, referrals, follow-ups and other actions. * Collects and records data and prepares required reports. * Serves as link between BSHC and other service agencies; Attends meetings and conferences and coordinates activities with these agencies. * Participates in training opportunities. * Adheres to the terms and conditions set forth in BSHC’s corporate compliance program. * Ensures confidential information in accordance with BSHC’s policy and current HIPAA regulations. * Performs other duties as assigned.   MINIMUM QUALIFICATIONS / REQUIREMENTS: * High school diploma or equivalent * Associate degree preferred * Excellent communication skills required * Previous experience communicating with the public * Ability and desire to work with others and demonstrates a concern for the health and social needs of patients * Valid Kentucky Driver’s License