Service Coordination, Navigation and Direct Service Skills: Connect patients to resources as needed, but not limited to medical homes and social services. Assist with follow-up appointments and care coordination. Organize and collaborate with strategic partners.Education and Facilitation Skills: Use learner-centered teaching to provide one-on-one and or small group health education and encourage patients to adopt positive lifestyle changes. Schedule and or deliver health education classes in designated communities.Individual and Community Assessment Skills; Outreach, Evaluation and Research Skills: Provide assessment and documentation of patients health-related social needs and assets; participate in family and community assessments. Coordinate with team members across various project requirements. Assist with developing and implement assessment tools for project longevity and maximum positive patient outcomes.Communication and Organizing Skills: In coordination with community partners, serve as liaison between Dell Medical School and other community partners.Utilize written and verbal communication, and assist with building a foundation for long term solutions.Other related duties as assigned.