Conducts thorough assessments of clients' medical needs, considering physical, mental, and emotional health with additional assessment considering the social determinants of health; Develops a comprehensive understanding of clients' health histories and current health status; Develops individualized care plans in collaboration with clients, healthcare providers, and other stakeholders; Sets health goals and strategies to address clients' medical needs and enhance overall well-being; Collaborates with healthcare professionals to ensure clients receive appropriate medical care and treatment; Facilitates referrals to specialists, diagnostic services, and other healthcare resources as needed; Advocates for clients' healthcare needs within the healthcare system and community resources; Educates clients on preventive healthcare measures, medication management, and healthy lifestyle choices; Connects clients with relevant resources to address social determinants impacting their health; Maintains accurate and up-to-date records of client interactions, assessments, and care plans; Compiles and analyzes data for reporting and program improvement purposes. This role has an opportunity for systems-level advocacy, community education, and will work closely with other community service providers, including crisis services, outpatient, housing, justice system, first responders, and various community resource agencies.