Community Health Worker

Community Health Worker, HCT

We're unique. You should be, too.

We're changing lives every day. For both our patients and our team members. Are you innovative and entrepreneurial minded? Is your work ethic and ambition off the charts? Do you inspire others with your kindness and joy?

We're different than most primary care providers. We're rapidly expanding and we need great people to join our team.

The Community Health Worker, HCT is a vital HCT member, who will use a strong knowledge of the local community to help engage patients in our primary care model, deepening the patient relationship with us and the patient's understanding of their plan of care. The incumbent will increase pt engagement through relationship building, provide education through home visits and clinic groups, and facilitate visits with our physicians through video during these community visits. The Community Health Worker, HCT will also use telephonic outreach to assist patients with following treatment plans for intervention with Diabetes and Hypertension. The incumbent will work closely with our nurse care managers and social workers to support a multidisciplinary approach to meeting our most complex patients' medical and social needs. Additionally, the incumbent will also support the HCT with patient scheduling and other tasks as determined by the team leaders.

ESSENTIAL JOB DUTIES/RESPONSIBILITIES:

• Screens Patients for eligibility with intervention program for Diabetes and Hypertension.
• Completes initial social and medical history intake, as well as SDOH social Wellness screening.
• Completes home and office visits with patients on their caseload to provide education support and intervention. Assists patients in their homes with telehealth visits with their Primary Care Physicians
• Works with patients assigned to us, but not actively engaged in care to link them to our physicians with the goal of full engagement in our model of care.
• Assesses patient need for transportation to and from the appointment and coordinates with centers to schedule or assist patients with their health plan transportation policy for specialty appointments outside our centers.
• Links patient and family with community resources when necessary, including assistance with patient and family on completion of a Medicaid Application and other application for programs for which they may be eligible.
• Performs discharge phone calls within 24-72 hours post discharge from inpatient setting. (Hospital, SNF, Long Term Acute Care Hospital (LTACH) using post discharge script explaining our services and obtaining consent for visits and upload to patient's chart.
• Communicates between patient and discharge champion in the center to assure patient has 4- day post discharge appointment to see their Primary Care Physician (PCP).
• Works collaboratively and effectively within the team of Community Nurse and Community Social Worker on their individual visit schedule, maintaining great communication with Nurse and Social Worker while maintaining their schedule and calendar.
• Coaches' patients in effective management of their chronic health conditions and self-care
• Motivates patients to be active, engaged participants in their health.
• Continuously expands knowledge and understanding of community resources, services and programs provided; human relations and the procedures used in dealing with the public as part of a service or program; volunteer resources and the practices associated with using volunteers, operations, functions, policies, and procedures associated with the department or program area, procedures, and resources available to handle new, unusual, or different situations.
• Attends meeting and reports on patients as assigned.
• Performs other duties as assigned and modified at manager's discretion.

KNOWLEDGE, SKILLS AND ABILITIES:

• Competent-level business acuity
• Comprehensive knowledge and understanding of general/core job-related functions, practices, processes, procedures, techniques and methods
• Strong interpersonal and communication skills and ability to work effectively with a wide range of people in a diverse community with our values of Love, Accountability and Passion.
• Ability to work autonomously.
• Strong time management skills and ability to prioritize patient visits and tasks.
• Comfort working in fast-paced setting with a willingness to adapt to change.
• Proficient in Microsoft office suite products including Word, Excel, PowerPoint and Outlook database and presentation software.
• Ability and willingness to travel locally to patient homes up to 50% of the time.
• Spoken and written fluency in English (bilingual preferred)

EDUCATION AND EXPERIENCE CRITERIA:

• High School diploma or equivalent required.
• Experience working with geriatric patients is a plus.
• Established track record of excellent data management skills.
• A minimum of 2 years working in healthcare setting with patient-facing responsibilities.
• A minimum of 2 years working directly with primary care physician in an outpatient setting is preferred.
• Any combination of three (3) years health/social services experience and/or education
• This position requires possession and maintenance of a current, valid drivers license.
• Basic Life Support (BLS) certification from the American Heart Association (AMA) or American Red Cross required w/in first 90 days of employment