Job Description Responsible for assisting patients referred to AHS for assistance in accessing and utilizing health care resources due to their complex chronic illness and co-occurring psychiatric diagnoses. Improves health outcomes through coordinating care, educating patients, building trust between patients and medical practitioners, and enhancing communication and the continuity of care. Teaches, counsels and monitors patients on health issues relevant to their care. Consults with other health care team members to coordinate the services of patient education, preventive care and disease management. Princi