This position acts as a liaison or link between health and social services and the community to facilitate access and improve health outcomes by increasing health knowledge for beneficiaries; this will be accomplished through a range of activities including outreach, community education, information counseling, social support, and advocacy.  This position is responsible for supporting those we serve in recovery, maintaining good mental and physical health, and managing symptoms in support of healthy goals.


ESSENTIAL POSITION FUNCTIONS (listing Position Specific functions first):

  • Effectively provide Behavioral Health Home (BHH) communication, written and oral, for community stakeholders and providers specific to the service they offer.
  • Lead BHH team in developing inter-agency relationships.
  • Identify, contact, and establish ongoing relationships with community stakeholders and providers to support medical and psychosocial needs of beneficiaries.
  • Recognize and identify needs of beneficiaries to ensure adequate internal and external resources are provided for health, safety, and social determinants of health.
  • Create and maintain beneficiary resource guide throughout NLCMHA catchment area.
  • Coordinate patient care huddles with appropriate community providers and NLCMHA staff.
  • Responsible for meeting agency performance expectations related to billing.
  • Responsible for completing portions of health risk assessment and social determinants of health.
  • Responsible for completing portions of care plan.
  • Coordinate and provide access to individuals and family supports, including referral to community social supports.
  • Coordinate and communicate with medical providers, subspecialty providers including mental health and substance use disorder service providers, long term care and hospitals. 
  • Implement wellness and prevention initiatives and facilitate health education groups.
  • Assist with obtaining follow up care, referrals, and conducting referral tracking.
  • Identify community resources for beneficiaries to utilize and maximize wellness.
  • Provide home visits as needed to ensure stability through transitions.
  • Provide education regarding health conditions and strategies to implement care plan goals.
  • Collaborate and coordinate with community-based organizations and key community stakeholders.
  • Advocate for individual and family needs.
  • Use of Electronic Health Record (EHR) and other Health Information Technology (HIT) to link services and facilitate communication among team members and provide feedback.
  • Work as part of a multi-disciplinary team to mentor, educate, and support one another and BHH beneficiaries.
  • Monitor the effectiveness of interventions in care plans.
  • Ensure that documentation is accurate and completed in a timely manner. 
  • Act in a professional manner reflecting the mission and philosophy of NLCMHA.
  • Build and maintains positive working relationships.
  • Attend and participates in staff meetings as required.
  • Other applicable duties as may be assigned.


  • Bachelor’s Degree in Public Health, Health Education, Health Promotion or related field.
  • At least 2 years experience directly related to the duties and responsibilities specified.
  • Knowledge of medical terminology preferred.


  • Must be qualified in Basic Life Support techniques.