Community Resource Advocate - Med. Group

Medical Home
Work Hours
Position Type
Regular Full-Time
Hours Per 2-Week Pay Period
80 Hours
Weekend Requirements
Weekends and holidays as scheduled


Under the supervision of the Director of Care Management & Quality, the Community Resource Advocate is

responsible to assess, plan, organize, coordinate, administer, and evaluate social needs within the medical home project. The Community Resource Advocate is responsible for facilitating access to health care for patients. The Community Resource Advocate works collaboratively with multidisciplinary team and assists in developing and maintaining needed resources. S(he) needs to be emotionally mature, objective, and sensitive to people and their problems. Ability to make appropriate decisions with a minimum amount of supervisory direction. Regularly use independent judgment to interpret and apply policies, procedures and practices.


Special Criteria Details

One hour lunch


  1. Provide assessment, counseling, education and resource referral to individuals and families that have been identified within the medical home guidelines including but not limited to:
  • Identify barriers to achieving optimal health outcomes utilizing motivational interviewing techniques.
  • Provide education to patients and their family about care plan, importance of follow- up, risk factors and resources available.
  • Assess and address behaviors to promote healthy living with emphasis on prevention, self-management and promotion of behavioral changes.
  • Provide access to social services and assistance to improve the social and emotional functioning of patients and their families.
  • Communicate care plan with patient and families when appropriate in collaboration with multidisciplinary team.
  1. Provide a coordinated dialogue between providers and patients and assist them through the continuum of services including but not limited to:
  • Identify referral needs and coordinate referrals to other social service agencies.
  • Assist in identifying and resolving barriers to a smooth discharge from an in-patient facility to home.
  • Assist with early identification of patients either at risk for poor outcomes to avert preventable emergency room use as evidenced by a decrease in ER utilization.
  • Act as patient advocate as appropriate.
  1. Promote healthy lifestyles and improved services throughout the communities including but not limited to:
  • Provide education to promote a healthy lifestyle across populations within the community.
  • Be an advocate for improved community services. Involved in planning or policy development.
  • Provide care management services to patients identified for the adult/children Health Home, as needed.
  1. Maintain skill competency.
  2. Demonstrate commitment to continuing education
  3. Comply with HIPAA and UVM Health Network – CVPH confidentiality policies.

Other duties as assigned.


  1. Bachelors degree in social work, counseling or related field with 2 years relevant experience or Associates degree in human services or related field with 3 years relevant experience required.
  2. Excellent attention to detail required.
  3. Strong verbal and written communication skills required.
  4. Ability to effectively manage multiple cases and projects required.
  5. Ability to develop and maintain effective relationships with staff, providers, patient’s, families and external customers required.
  6. Proficient computer competencies including Microsoft applications required.
  7. Ability/experience with data collection, program management and reporting required.
  8. Health care experience a plus
  9. Medical terminology experience preferred.


As applicable, the individual has training/competency in attending to the special needs and/or behaviors appropriate to the age of the patients for which care is being provided.


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