Community Health Worker - Oak Orchard Health

Job Title

Oak Orchard Community Health Worker

Reports to

FLIPA Community Health Worker Supervisor and Oak Orchard Patient Engagement Services (PES) Manager

Social Care Network Summary

The New York State Department of Health has established Social Care Networks (SCNs) as part of the 1115 Waiver Demonstration Amendment, The SCN’s aim is to enhance the delivery of social care services to Medicaid members by coordinating efforts among community-based organizations (CBOs) and other health care partners to create a more resilient, flexible, and accessible social care system that reduces health disparities and advances health equity. The SCN will collaborate with CBOs and other health care partners, leveraging shared data and technology to coordinate social care services for Medicaid members to improve access, ensure reliable and timely referrals, streamline and track navigation and completed referrals in closed loop systems and enhance collaboration between social care service providers and other regional partners.

Job Summary

This position is responsible for establishing trusting relationships with patients while providing support in navigating and accessing resources and engaging patients in goal-driven care. The Community Health Worker systematically identifies, assesses, refers, and monitors high-need individuals to ensure access to essential services while supporting providers and the Care Team through an integrated approach to care management and community outreach.

This position is funded through March 2027.

Organizational Overview

Forward Leading IPA (FLIPA) is a nonprofit membership association of safety net providers working in partnership to provide the highest quality integrated healthcare to historically underserved populations in Upstate New York since 2017. FLIPA is renowned for its commitment to integrating primary care, behavioral health, and social care needs. Our growing membership serves individuals across Upstate NY and includes federally qualified health centers (FQHCs), behavioral health providers, and a rural health network consisting of eight county public health departments.

Equal Employment Opportunity Statement

At Forward Leading IPA (FLIPA), we deeply value diversity in background, experience, and thought. We are committed to creating an environment of belonging where all qualified applicants are encouraged to apply and will receive equal consideration for employment. We do not discriminate based on race, color, religion, age, sex, gender identity or expression, national origin, disability status, veteran status, or any other characteristic protected by federal, state, or local laws.

Security Level

Shared Staff - FLIPA

Duties / Responsibilities

• Provide a vital link between local communities and healthcare provider by helping individuals access resources and navigate systems.
• Proactively outreach and engage identified individuals in need of services, follow up or social care screening by connecting via phone calls, home visits and/or in-person visits to other settings where patients can be found.
• Support deployment of NYS Social Care Network screening and referral process
  • Engage directly with Medicaid individuals to administer the Health-Related Social Needs Screening Tool to identify needed areas of support.
  • Facilitate referrals to appropriate community resources and healthcare providers.
  • Collaborate with the Care Team to ensure timely follow-up and service linkage.
  • Use designated online referral systems and databases to track and manage client referrals.
  • Provide care management related to social care services
  • Assist individuals with transportation in support of obtaining services related to social care needs.
• Accurately document in electronic systems and maintain detailed and organized records in compliance with organizational policies and standards.
• Work closely with the Care Team, including care coordinators and other healthcare professionals, to align to a whole person care approach.
• Participate in regular team meetings and contribute insights on client progress.
• Attend regular supervision, staff meetings, trainings and other meetings, as requested.
• Other duties as assigned

Education & Experience

• Minimum of High School Diploma or GED.
• Associate's degree in human services, Social Work or other related degree preferred.
• Equivalent experience in lieu of education may be considered.
• Minimum of 1-3 years' human services experience.

Skills, Knowledge, and Abilities

• Possess excellent verbal and written communication skills.
• Exceptional customer service skills with commitment to helping others.
• Ability to quickly adapt and be flexible in approach to job tasks and challenges and maintain emotional control under stress.
• Excellent time management skills with exceptional attention to detail and the ability to multi-task and manage multiple priorities with competing deadlines.
• Capability to work cooperatively with culturally diverse clients, staff, and community service providers.
• Basic computer literacy, including the ability to use email, conduct online research, and create basic documents (MS Office Suite including Excel, Outlook and Word).
• NYS motor vehicle license, safe driving record and availability of personal vehicle for work.
• Holds self and others responsible and accountable to meet commitments.

Salary Range

• Hourly is commensurate to education and experience of $26.44 per hour

Additional information

• This position is an in-person role, embedded within Oak Orchard, a FLIPA member organization.
• This position will be located Batavia NY with potential to work at other locations in Genesee County.