Responsible for working with patients, providers, and sites to provide data coordination, outreach to patients with chronic illnesses such as diabetes, hypertension, asthma, or behavioral health conditions, arrangement of preventive health screenings, and provision of assistance arranging or coordinating necessary care. Communicates and collaborates with OPH nurses and care coordination staff to optimize patient care, and supports patient care plans by assisting with linkages to, coordination of, and monitoring identified service needs.