Community Health Worker

The Community Health Worker work entails outreach to patients, engaging them in care management, setting up routine contacts and tracking and follow-up, co-creating care plans with them using motivational interviewing techniques, working on self-management goals, providing links to outside resources when needed, follow-up after any hospitalization or ED visit, and documentation of each direct patient contact or interaction about the patient with others on the care team. This role tightly works with the RN Care Manager, with daily huddles reviewing patients needing follow-up today/this week, any challenges happening, new patients engaged, and understanding when the care manager should be brought in to talk with the patient, and when a case review with the PCP is needed. Scheduled Hours: 37.5 hours per week Complete all required training sessions and activities. Use outreach tools and technique to contact patients and engage then in the Complex Care Management program. Build rapport and connection with patients in an empathetic manner. Collaborate with patient (and family/advocate at patient request) to understand their health care needs and goals. Develop with the patient a care plan. Review care plan with patient at every contact for progress, additional assistance, or any flags that need to elevate to the RN Care Manager or PCP. Build competency in using motivational interviewing techniques to help patients. Use tracking tool to routinely follow-up with patient in the active caseload. Review caseload with RN Care Manager on a daily basis for those not making improvement, new patients, complex or more challenging situations, and determine which patients the RN Care Manager will see/contact, and if any need to be escalated to a case review with the PCP. Participate in care reviews with the PCPs as needed. Screen patients for health and Social Determinants of Health (SDOH) issues and make service referrals or enroll patients in services as appropriate. Link patients to social services programs and entitlements such as transportation assistance and transportation services. Provide patients with resource information by utilizing local database systems. Assist patients in scheduling, accessing, and utilizing health services with their primary care provider (PCP). Refer patients with complex health and social needs to the appropriate community-based organization for additional support. Distribute educational and health materials when appropriate. Instruct and educate patients on procedures, healthcare provider instructions, and referrals. Maintain records of care management activities. All other duties as assigned. High School Diploma required. Must have experience working in community work. This can include advocacy, volunteering, or community organizing. Case management experience is a preferred. Spanish or other language fluency is a preferred. Flexibility to work evening and some weekend hours required. Driver’s license or ability to travel throughout the county to various locations (vehicles available for licensed drivers). As the largest human service provider in Lake County, we believe that services must be available without barriers. No residents are turned away due to the inability to pay. We believe in providing services in an environment of mutual respect, free of discrimination or bias. Whether assuring accessible and effective care, impacting policy, or assessing and monitoring risks, the Lake County Health Department and Community Health Center has been an essential part of the public health system in Lake County for 60 years. We are looking for passionate, qualified team members who can help make a difference in our agency and, most importantly, in our community. Additional information about the Lake County Health Department, our culture, and why you should join our team can be found at At this time, you must live in Illinois or Wisconsin to be eligible to work at Lake County Health Department. You can find our salary grades at For unionized positions, a list of our collective bargaining agreements can be found here: This position is represented by AFSCME Council 31. Any offer of employment is conditioned on the successful completion of a background screening, drug and alcohol testing and may include a pre-employment medical exam. The Lake County Health Department and Community Health Center is an Equal Opportunity Employer. We evaluate qualified applicants without regard to race, color, religion, sexual orientation, gender identity or gender expression, national origin, disability, veteran status, and other protected characteristics. #J-18808-Ljbffr Lake County, IL