Implemented a whole-person approach to integrate physical and behavioral health services in identifying, assessing, and addressing clients' physical, behavioral, and social needs. Provided telephonic and on-site support to help individuals navigate the health care system. Coordinated medical and behavioral health services to close gaps in care. Monitored clients transition to home post-discharge, reconnected them with their healthcare team, and blended telephonic and in-person outreach to maximize client engagement. Promoted collaboration between programs and services, physicians and pharmacists, and community resources to identify appropriate services, education, and interventions.

Engaged clients with chronic and complex conditions through care coordination to reduce inappropriate hospitalization. Bridged communication between patient, primary care, specialists, and caregivers. Assisted patients in navigating the health care system, while responsible for providing clinical and medical management services, including health assessments, at-risk prevention and intervention, and discharge planning.

Enrolled cases in an Early Head Start Home-Based program for child development. Maintained Family Partnership Agreements through home visits and virtual 1:1 meetings to support parents/guardians to achieve self-sufficiency goals. Connected clients with in and out-of-network resources. Facilitated Adult groups centered around parenting and single father parenting.

Managed a caseload through provision of case management services, community resource referrals and participation in weekly client meetings to set family partnership goals, track referral progress and prepare for transitions. Conducted Adult Literacy workshops. Co-facilitated Youth groups centered around bullying, prevention, self-esteem and self-confidence.