Community Health Worker

Community Health Worker

Requirements

• Bachelor’s degrees and/or minimum of two years of relevant health care experience required
• Prior care coordination or case management experience
• Bilingual in Spanish or other languages spoken by people in the communities we serve, strongly preferred
• Experience utilizing electronic medical record systems
• Knowledge of community resources and resource navigation
• Experience with motivational interviewing, behavior change, health promotion, and coaching
• Knowledge of payer managed care programs preferred
• Strong verbal and written communication skills and customer service orientation
• Accomplished problem-solving skills and a highly flexible and accountable work ethic
• Experience working with multiple software platforms, electronic health records, google suite, including gmail and google documents, spreadsheet development and navigation, data processing
• Excellent organizational skills and ability to manage multiple priorities appropriately
• US work authorization

Responsibilities

• Manage low risk referrals defined by care management program (Medical Social Work) and collaborate with social worker on action plans
• Form relationships with patients and their caregivers to support prevention focused care and ED/ hospital diversion, and focusing interventions on reduction of avoidable hospital admissions
• Meet with patients in patient centered and patient preferred location (e.g., center, facility, home, community setting)
• Drive engagement with high risk individuals (e.g., completed specialty appointments, adherence to Post discharge visits) may include accompaniment to appointments
• Assist with completion of applications to access eligible benefits
• Conduct wellness checks in home, participate in remote monitoring program education on individuals with specific health conditions
• Facilitate communication between all identified parties for the patient involved in care (e.g., family members, care givers, medical providers, community-based organizations)
• Partner with patients to identify their goals, increase engagement in care and reduce barriers to achieving healthcare goals and execution of their care plan
• Navigate Managed Care plans and resources to ensure mindful utilization
• Manage an assigned caseload while remaining in compliance with all internal and regulatory requirements (where delegated services are active)
• Collaborate with internal care teams as well as external healthcare professionals, patient social supports and insurance resources to assess the patient’s healthcare needs and ensure successful outcome of care plan goals
• Scheduling, leading and maintenance of interdisciplinary care team (ICT) meetings (where delegated services are active)
• Conduct assessment(s) to identify individual patient needs and goals, develops a specific patient-centered care plan to address problems, sets goals and interventions as identified during the assessment
• Maintain HIPAA standards and confidentiality of protected health information
• Capacity to transport oneself to members’ homes and facilities and comply with travel and mileage reimbursement policies
• Complete all activities and interventions outlined in the members care plan and ongoing monitoring of cases to ensure routine follow up and progression in their care plan goals
• Partner with Care Team throughout managed patients’ inpatient and post acute episodes of care
• Maintain clear documentation of patient enrollment and progression through programs within compliance timeframes
• Practice in accordance with applicable laws and standards, and ethical principles
• Perform other job duties as requested by Care Management leadership team
• Participate in compliance audits of caseload (where delegated services are active)

Preferred Qualifications

• Knowledge of payer managed care programs preferred