Chronic Care Manager & Community Health Advocate

If you are unable to complete this application due to a disability, contact this employer to ask for an accommodation or an alternative application process.

CHRONIC CARE MANAGEMENT COMMUNITY HEALTH WORK

Hempstead, NY, US 2 days ago Requisition ID: 3046 Salary Range: $23.00 To $25.00 Hourly

OUR VISION

To continue as an eminent healthcare provider on Long Island, dedicating ourselves to providing exceptional health care for all our patients and to transform both the lives of the individual, and the community, for the better, one person at a time.

OUR MISSION

To provide access to equitable, optimal healthcare by improving the overall wellness of all individuals in our communities and delivering high quality comprehensive patient centered care. JOB TITLE: Chronic Care Management Community Health Worker REPORTS TO: Assistant Director of Care Coordination The following statements reflect the general duties, responsibilities, and competencies considered necessary to perform the essential functions of the job and should not be considered as a detailed description of all the work requirements of this position.

POSITION SUMMARY

The Chronic Care Management Community Health Worker (CCM CHW) supports the Chronic Care Management program by serving as the key liaison between patients and the care team. This role focuses on maintaining consistently monthly patient contact, reinforcing care plans, and relaying patient needs and updates back to the interdisciplinary team. The CHW works under the guidance of providers and nursing staff to support patient engagement, self-management, and adherence to treatment plans.

RESPONSIBILITIES

Patient Engagement & Monthly Coordination Identify eligible patients, introduce CCM services, and enroll in CCM program by obtaining consent. Conduct consistent monthly outreach telephonically. Build rapport and maintain ongoing engagement with enrolled patients. Perform follow‑up calls related to chronic condition management. Identify and escale barriers to care (appointments, medications, social needs). Document all patient interactions in accordance with CCM requirements. Care Plan Reinforcement Review Care Plans with patients to ensure understanding. Reinforce individualized goals, self‑management strategies, and next steps. Identify barriers to adherence and escalk concerns to the care team. Identify when updates are needed and notify providers. Medication and Self‑Management Support Review medication adherence with patients (non‑clinical). Support patients in understanding prescribed regimens and routines. Encourage chronic disease self‑management techniques. Participate in team huddles with providers and nursing staff. Receive direction and task prioritization from clinical and care coordination leadership. Maintain ongoing communication with assigned Nurse Care Manager. Care Coordination Feedback Loop Coordinate care across providers, specialists and community resources. Track referrals, lab results, and follow‑up needs. Support transitions of care activities by following up with patients discharged within 48 business hours of notification and assisting with scheduling post‑discharge care. Focus on closing Gaps in Care (GIC). Participate in monthly Multidisciplinary Team (MDT) meetings. Manage patient status and monitor progress toward health goals. Gather and report patient updates, concerns, and barriers. Contribute to team‑based strategy development for complex patients. Assist in implementing agreed‑upon care strategies with patients. Documentation & Time Tracking Document CCM activities in the electronic health record (EHR). Track accurate time spent on qualifying CCM services. Quality & Compliance Ensure CCM services align with regulatory requirements. Participate in audits and quality improvement activities. Maintain HIPAA compliance. May be assigned other tasks and duties reasonably related to job responsibilities.

COMPETENCIES

Possesses strong patient engagement and relationship building skills. Manages multiple patients and prioritizes tasks effectively. Executes follow‑up timely and has strong organizational skills. Demonstrates strong interpersonal skills including effective oral, written, and telephonic communication with patients and care team. Manages time efficiently and completes CCM activities consistently and timely. Demonstrates initiative and presents as goal‑oriented and accountable. Collaborates with colleagues consistently and is able to work as part of a team. Documents activities and tracks time accurately. Follows structured workflows and compliance requirements. Identifies barriers to care and escalates appropriately. Works effectively with providers, nurses and Care Team members as well as specialists, hospitals and community resources/agencies. Supports and demonstrates team‑based care models within the Health Centers and within the Department. Adjusts to workflow changes and program needs. Understands cultural competency and displays empathy. Comprehends basic chronic disease management principles. Maintains openness to feedback and continuous improvement.

QUALIFICATIONS

High School Diploma or equivalent experience required. Bachelor's degree in health‑related field, Certified Medical Assistant (CMA), Certified Professional in Healthcare Quality (CPHQ) or similar certifications preferred. At least one year of experience in healthcare or case management required. Experience working with patients with chronic conditions preferred. Working knowledge of computer software and electronic health records. Understanding of chronic disease management concepts preferred. Familiarity with care coordination or population health workflows preferred.

SALARY

Commensurate with experience

MORE INFORMATION

This is a non‑exempt position.

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to perform a range of physical activities that are essential to the core work functions outlined in this document. #J-18808-Ljbffr Harmony Health Care Long Island