Find & Apply For Community Health Worker Jobs in Greenfield, California

JOB SUMMARY

The Empanelment Coordinator will manage Primary Care Provider (PCP) panels, assist patients to access targeted care, improve the quality of chronic care service delivery, assist medical providers in care management, & provide ongoing education & promotion to eligible patients in the healthcare system. This role will work to identify unmet care needs, and in collaboration with the health care team, target interventions to improve the health outcomes of patients via patient outreach and promotion of preventative services, mental and physical wellness.

PERFORMANCE DIMENSIONS AND TASKS

Essential Functions 1. Empanelment a. Receive, maintain, review, and organize patient registries and panels, including new patients who are being accepted into our healthcare system. b. Assesses panel size to determine PCP capacity to absorb new patients. c. Understand and maintain knowledge of PCP staff and care teams, what the roles are in the healthcare system, and what services they offer to the patients. d. Recommend to the medical director and/or management team to close or open provider panels according to panel capacity e. Review issues with Medical Director, as needed f. Reassign patients to other PCPs as appropriate for complexity and services rendered. g. Assign unassigned patients by reviewing appointment history (and possibly the clinical record) to determine appropriate assignment. h. Track patient status changes including death, transfers to other care, and make the change in the practice management system. i. Facilitate discussion between and obtain approval from current assigned PCP & future PCP j. Make PCP assignment changes in the practice management system/EHR k. Manage the Provider-initiated PCP change requests. l. Obtain agreement of acceptance by the new PCP m. Track provider status changes (transfer, termination, sabbatical, medical leave, etc.) n. Evaluate impact on assigned panel of patients and scheduling o. Reassign panel to other clinic providers according to panel capacity p. Notify affected patients of new PCP assignment 2. Commitment to Quality Improvement & Team Success a. Contribute to quality improvement & team success efforts by providing feedback and progress reports to management teams on health status and outcomes of panels. May also serve as a member of the Quality Improvement Committee. b. Collaborate with other health care team members, such as health educators, to support individual or group-based interventions of care. c. Attend Quality Improvement meetings and other meetings that support Panel Management, health education, and community based resources. 3. Community Health Worker a. Provide patient outreach for community members advocating for culturally relevant health education, promotion of preventative care services available to them, and provide details on access and coordination of services. b. Accept referrals for patients who are in need of CHW services and process those referrals in a timely manner, according to clinic policy. Develops and maintains working relationships with clients and makes referrals to other community agencies and services. c. Attend or participate in community based events that will promote health services and engage proactively with community members who are in need of resources. d. Knowledgeable of community and county wide resources that are available to patients based on their needs, and be able to connect them directly to those applicable services. e. Must have a close understanding of the community that they are serving patients in and what unique challenges are anticipated in each area. f. Goal is to build individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support, and advocacy. g. Interviews clients to obtain basic data, past medical history, and determines income status/program eligibility, along with Social Determinants of Health barriers to care. h. Conducts outreach (e.g., follows-up on health and social service encounters with individuals, families, and community groups; to provide education, assessment, and social support; presents at local agencies and community events).