Job Details: Level: Experienced, Job Location: West Waco Clinic - Waco, TX, Position Type: Full Time, Education Level: 4 Year Degree, Salary Range: Undisclosed, Travel Percentage: None, Job Shift: Day, Job Category: Health Care, REPORTS TO: Director of Primary Care Behavioral Health EDUCATION & EXPERIENCE: Master’s degree in social work, public health or administration, or any related field, or bachelor’s degree with commensurate experience in these fields SKILLS:  Basic understanding of chronic care management and primary care systems Ability to navigate health care systems General knowledge of chronic health care conditions and needs Ability to communicate across disciplines Familiarity with coordinating support services for patients  Excellent written & verbal communications Bilingual (English/Spanish) ability is preferred and reflected in compensation   Qualifications: PRIMARY DUTIES: Implement and support care management for patients with medical and behavioral disorders. Coordinate with primary care teams, and collaborate with community partners to address unmet needs for at-risk patients. Provide problem-solving assistance and decision-support to primary care teams implementing care management. Perform advanced care management tasks including pre-visit planning, providing patient education, monitoring registries and supporting patient self-management Provide care coordination services to address short- and long-term medical and behavioral health treatment goals Communicate with physician and care team members about relevant patient needs or changes OTHER DUTIES: Other duties as assigned by supervisor PHYSICAL AND MENTAL REQUIREMENTS: Visual and auditory accuracy Shift length - 8 hours Indoor setting Frequent use of computer Long periods of sitting Frequent use of telephone Continuous repetitive grasping and manipulation of both hands Continuous conversational communication Occasional reaching, walking, squatting, bending, kneeling, twisting and climbing Occasionally carrying, lifting, pushing and pulling of up to 25 lbs. Occasionally working in confined, noisy, dusty areas Periodic use of personal transportation Understand/carry out simple/detailed, oral/written instructions with retention Read and interpret detailed specifications