OneCare Kansas Patient Engagement-Pittsburg, KS

POSITION: Patient Engagement Specialist

DEPARTMENT: Patient Engagement

REPORTS TO:  Director of Patient Engagement, Patient Engagement Manager




The core values of Community Health Center of Southeast Kansas (CHC/SEK) are dignity and stewardship.  Each staff member is expected to perform their job duties in a way that preserves dignity for our patients and maintains good stewardship of the Center's resources.


The Patient Engagement Specialists (PESs) at CHC/SEK are motivated, and passionate about improving health outcomes for patients with chronic disease. They strive to understand, motivate, and help our patients achieve their goals in health and wellness by building rapport, eliminating barriers, collaborating with patients to set goals, and working within a multidisciplinary care team. PESs go above and beyond, often assisting patients through innovative methods in nontraditional locations such as a patient’s home or in the community. PESs must be flexible, knowledgeable about disease processes, community resources and CHC/SEK care systems, and able to address barriers to improved health outcomes. 

This position is part of the Patient Engagement team, which focuses on clinical and non-clinical care management and coordination, benefits enrollment, social service navigation, community outreach, home visits, and administering patient-centered education and programming. The team utilizes evidence-based practices to outreach to defined patient populations and receives referrals from both the clinical staff and community partners to advance key community health indicators.


  1. Engage high-risk, underserved populations, and work to decrease the impact of exacerbations on health status and accelerate recovery through targeted care management.
  2. Support care management and coordination services across all Patient Engagement populations including OneCare Kansas, Chronic Care Management, and the Community Health Action Team.
  3. Enroll patients into related programs and provide coordination and management of care within an interdisciplinary team that further supports retention, wellness, and overall health.
  4. Meet patients, and community members in the home, clinic, or community setting and conduct needs assessments, and screenings, including identification of socio-economic issues that affect their overall health.
  5. Provide care management services on an ongoing basis to provide continuity throughout a high-risk patient’s care, which may mean working with the same patient for a few months to a year or more.
  6. Assist patients in understanding care plans that include clear goals, priorities, and realistic actions to achieve their goals. Support progress by making and attending follow-up appointments, scheduling and providing transportation, accessing prescriptions, or other means as needed.
  7. Use skills like motivational interviewing and shared-decision making to engage patients in the development of health and social support goals, coaching patients in the effective management of their health conditions and utilizing self-care techniques.
  8. Assess the patients’ unmet health and social needs to connect with community and organizational resources, including clear guidance about why and how to access these resources.
  9. Work from a strength-based perspective to emphasize a patients internal and external resources.
  10. Build trusting relationships and follow up with patients about their health via phone calls, home visits, and visits to other settings as needed, serving as a liaison between the community and the health care system.
  11. Practice cultural humility, avoid making assumptions about the knowledge, behaviors, or values of patients, working to transfer power to patient through self-management skills.
  12. Assist with assigned outreach activities such as delivering prescription medications, attending health fairs, or attending other outreach events, as directed.
  13. Utilize technology and telehealth capabilities to better connect the patient to care.
  14. Work collaboratively, respectfully, and effectively within the Health Advancement team, a patient’s support system and clinical care team.
  15. Build and maintain positive, supportive working relationships with clients, patients, providers, community organizations, and others.
  16. Contribute to and utilize data to achieve program goals, improve health outcomes, and advance community health indicators.
  17. Work to address health disparities for vulnerable populations by looking to innovative workflows and processes, or contributing to operational changes.
  18. Maintain a library of health promotion and patient education materials and community resources.
  19. Perform other duties as assigned.



  1. Licensed health professional in the field of nursing, social work, or mental health or a Bachelor of Science in a related field (e.g. health promotion, healthcare administration, public health, etc.)
  2. Minimum of two (2) years of healthcare related experience, preferably in an outpatient setting.
  3. Previous care management and/or behavioral health experience preferred.


  1. Must possess and demonstrate a high degree of leadership, organizational ability, and communication skills.
  2. Social and cultural sensitivity appropriate to ethnically and economically diverse patient-and employee-base
  3. Demonstrate knowledge of the rationale of appropriate patient care.
  4. Communicates through appropriate channels. Use proper chain of command for patient complaints.
  5. Ability to handle emergency situations calmly and effectively.
  6. Must be computer literate.
  7. Must have a strong working knowledge of the organization’s EHR.
  8. Must be able to maintain good inter-personal relationship with co-workers and other members of the health care team and the organization.
  9. Provide customer service in accordance to the organization’s mission.
  10. Be courteous and respectful when interacting with patients and family members.
  11. Maintain patient confidentiality in accordance to organization’s policy and procedure and HIPAA requirements.


While performing the duties of this Job, the employee is regularly required to sit; use hands to finger, handle, or feel; reach with hands and arms and talk or hear. The employee is frequently required to stand. The employee is occasionally required to walk.  The employee must regularly lift and /or move up to 10 pounds and occasionally lift and/or move up to 25 pounds.  Specific vision abilities required by this job include close vision, color vision, peripheral vision, depth perception and ability to adjust focus.