CHW (ECM) Intake Liaison

Job Summary:

The CHW (ECM) Intake Liaison coordinates successful engagements and transitions of care, provides Enhanced Care Management (ECM) services, and drives community outreach and marketing efforts. This role combines intake coordination, care management, and community engagement to ensure exceptional patient experiences and program growth.

Intake Coordination:

1. Manage incoming referrals, ensuring timely and accurate processing. 2. Conduct initial assessments, identifying patient needs and ECM requirements. 3. Coordinate with healthcare providers, ensuring smooth transitions. 4. Ensure the client is authorized to receive ECM services. 5. Assist the supervisor in aligning clients with other CHWs based on needs. 6. Keep outreach list current and up to date with all efforts made.

ECM Services:

1. Carry a minimum caseload of 20-25 patients. 2. Provide patient-centered care management, addressing social determinants and health needs. 3. Develop personalized care plans, promoting empowerment and self- management. 4. Conduct patient assessments to identify health and social needs. 5. Develop customized care plans and collaboration with patients, families, and healthcare providers. 6. Provide education and support on chronic disease management, healthy behaviors, and self-care. 7. Facilitate access to community resources, services, and referrals. 8. Coordinate care transitions and communicate with healthcare providers. 9. Conduct regular home visits and phone follow-ups to monitor patient progress. 10. Document patient interactions and care plans in electronic health records. 11. Collaborate with interdisciplinary teams to address patient needs and improve health outcomes. 12. Identify and address social determinants of health and health disparities. 13. Provide cultural competency and linguistically appropriate services. 14. Maintain patient confidentiality and adhere to HIPAA guidelines. 15. Ensures correct CPT codes and QIP measures are captured with each visit. 16. Completes documentation of visits and close encounters within 24 hours. 17. CHW minimum productivity is expected to be 80% clinical (patient billable encounters) and 20% Non-productive (driving/documentation/outreach etc.). 18. Schedule 75% of clients before the 15th of each month.

Community Outreach and Marketing:

1. Develop and implement outreach strategies, engaging diverse community populations to raise awareness of the ECM program. 2. Build partnerships with community organizations (Hospitals, MD clinics, outpatient clinics, schools, senior centers, YMCA), promoting program awareness. 3. Design and distribute marketing materials, highlighting program benefits.

Requirements:

1. A bachelor's degree in psychology, social work, human services, or a related field. 2. Community-based work or in-vivo work is required with proper safety precautions. 3. Certification as a CHW (CCHW) or willingness to obtain within 18 months. 4. CPI and CPR within 60 days of hire. 5. Strong communication, interpersonal, and cultural competency skills. 6. Ability to work independently and as part of a team. 7. Basic computer skills and familiarity with electronic health records. 8. Valid driver's license and reliable transportation (required).

Preferred Qualifications:

1. Certified as a CHW (CCHW). 2. Experience in providing ECM services. 3. Experience in intake coordination, care management, or community outreach. 4. Experience working with diverse populations and communities. 5. Knowledge of community resources and services. 6. Familiarity with care management software and technology. 7. Bilingual or multilingual skills.

Working Conditions:

1. Work in patient's homes, community, FQHC, Hospital, out-patient clinics, and office environments. 2. Flexible schedule (8 hours if 80% clinical productivity is met), including evenings and weekends for special events and outreach. 3. Travel to patient's homes and other community locations.

Job Types:

Full-time, Part-time Pay:

$26.00 - $31.00 per hour

Benefits:

401(k) Dental insurance Health insurance Life insurance Paid time off Vision insurance

Work Location:

In person