Job Description

Job Title: Community Health Worker

Reports to: Lead Care Manager Leader

Department: Enhanced Care Management (ECM)

DOL Status: Non-Exempt

Job Summary: The Community Health Worker is a field-based member of the ECM Care Team who has lived experience in the ECM Patients’ community and serves as the bridge between the ECM Patient and the healthcare system. The Community Health Worker is responsible for helping patients and their families navigate and access community services, access health care services, and adopt healthy behaviors.

Essential Functions:

• The CHW focuses support on ECM Patients who are difficult to engage and/or who have cultural or linguistic barriers to care via field-based contacts including accompaniment to appointments.
• CHW assists the RN Care Manager, BH Care Manager and Care Coordinator in panel management by performing delegated activities as assigned.
• Assists the ECM Care Team in engagement efforts of eligible ECM Patients in the clinic and within the community.
• Assists Patients in navigating the healthcare system and community resources.
• Follows-up by phone and in person with eligible ECM Patients and patients enrolled in ECM.
• CHW helps Patients successfully participate in their medical and/or behavioral health care by overcoming barriers to care and sharing information on barriers with the multi-disciplinary team and providers.
• CHW is responsible for engaging with patients, both in-person and on the phone, in a manner that utilizes evidence-based approaches (such as Motivational Interviewing) and promotes collaboration between the Patient and his or her medical/behavioral team.
• Collaborates on Patient care issues with other ECM Care Team Members, participating in weekly systematic case reviews and ad hoc case reviews, and consults with Registered Nurse Care Manager and/or the Behavioral Health Care Manager before taking any action that is clinical in nature.
• Accompanies ECM Patient to office visits, as needed, and in the most easily accessible setting, within health plan guidelines.
• Engage Patients in the hospital through in person visits when able.
• Engaging members that are eligible but not yet enrolled, as well as those currently enrolled in ECM to re-engage for follow up after discharge.
• Distributes health promotion materials.
• Connects ECM Patient to other social services and supports he/she may need.
• Advocates on behalf of the Patients with health care professionals; and monitors treatment adherence (including medication and Shared Care Plan goals)
• Conducts periodic telephonic and in-person outreach and follow-up with ECM Members as outlined in the Shared Care Plan.
• Documents evidence of care in the member’s record in a concise and timely manner using the EHR system.
• Recognizes signs of child and elder abuse and reports appropriately to Child/Adult Protective Services.
• Understands and abides by all departmental and companywide policies and procedures.
• Performs other duties as assigned or required.

Qualifications:

• Education & Experience: High School Diploma or GED required. Minimum one year of experience working in a community-based setting required. Equivalent combination of education and experience that provides the skills, knowledge, and ability to perform the essential job duties, and which meets any required state or federal certification requirements.
• Language: Fluent in English (written and verbal). Bilingual preferred.
• License/certification: Current and valid Driver’s License and proof of auto insurance.
• Skills required:
  • Competent with computers, email, virtual platforms, Excel and other Microsoft Office based programs.
  • Excellent verbal and written communication skills, including the ability to convey and exchange information in a clear, effective manner.
  • Ability to identify problems and use logic and related information to develop and implement solutions.
  • Ability to work independently and carry out assignments to completion within the parameters of established policies and procedures.

Physical Requirements: Physical demands associated with office work and driving, including but not limited to:

• Consistently operating a computer, computer software programs, other office equipment such as a telephone, calculator, copy machine, and printer.
• Must be able to remain in a stationary position 50% of the time.
• Must be able to move around the office or community 50% of the time.
• Frequently moving or carrying office equipment weighing up to 15 pounds across offices.
• Ability to operate a vehicle and travel to meet with assigned members around the community, attend meetings and different office locations as required or requested.