Direct in-person and telephonic patient outreach 30%
Documentation 10%
Meetings, program development

Job Functions:

Job Function:

01. Work in collaboration with a multidisciplinary team of clinicians as part of the Care Coordination program to provide high quality, outcome-based, patient-centered care for patients to achieve safe transitions of care, improved patient experience, better health outcomes, reduced avoidable cost and utilization, and increased preventative care. Assist high-risk patients address social barriers to care, ensure sustainable connections to health care services, providers, and social supports, and engagement in their plan of care and health outcomes.

Job Function:

02. Participate in the AHS CHW training program and onboarding curriculum. Follow departmental policies, procedures, processes, and professional and care standards according to department and organizational guidelines. Regularly attend and actively participate in assigned intradisciplinary and interdisciplinary meetings, team meetings, supervisory sessions, and in-service training. Job Function 03. Engage in proactive community outreach efforts to identify individuals who may benefit from health services and programs. Ensure timely response to referrals from various sources within the health system and adhere to evidence-based care model and maintain documentation and performance metrics according to departmental processes and standards. Maintain a focus on empowering and motivating patients toward self-efficacy, making patient-centered changes in behavior and lifestyle, and long-term sustainable connections and support solutions to achieve their best health. Job Function 04. Meet patients in a medical office, hospital, home, or community setting to get to know the patient as a person, conduct a guided interview, complete a full SDOH screening, and review patient's health needs and concerns. Partner with the patient to set patient-driven goals for their health and the steps to achieve those goals during your work together. Maintain a focus on building rapport, motivational interviewing, effective listening, cultural sensitivity, and setting goals and expectations.

Job Function:

05. Make weekly follow-up calls and home visits to patients to help motivate patients to achieve their health goals. Connect patients with community resources to help with social issues like homelessness, substance abuse and hunger. Assist patients with enrollment in medical, social, and financial programs and benefits for which they are eligible, such as insurance and food stamps. Promote education on preventative healthcare measures, disease management, and healthy lifestyle choices in alignment with patient goals. Assist patients with navigating the healthcare system and accessing medical services including helping them to organize their medical records, schedule follow-up appointments, and access prescriptions.

Job Function:

06. Maintain a current knowledge base of community agencies and key contacts and assist with patient advocacy, navigation, and engagement with sustainable medical, social, insurance and benefit systems. Work within Social Services team to maintain an updated directory of community resources. Collaborate with healthcare professionals, social service agencies, and community organizations to ensure patients make sustainable connections with the most appropriate provider.

Job Function:

07. Ensure ongoing collaboration and communication with the larger interdisciplinary Care Coordination team, AHS/ACO practices, providers, and care team members to comprehensively address evolving psychosocial needs, medical needs, and plan of care. Maintain accurate and up-to-date documentation of all interactions, services provided, and outcomes achieved. Document each patient encounter in detail and prepare reports and documents as needed or requested. Provide patient-specific and caseload updates to supervising social worker and/or manager on a regular basis.

Job Function:

08. Other tasks as required by manager, director, or leadership.

Education:

High School diploma or GED required; higher educational degree a plus Experience Long-time resident of or familiarity with a community in the role's service area and good knowledge of the communities' challenges and resources. Prior experience as an outreach worker or customer-service experience a plus. Knowledge of community resources and social service, financial, insurance, and advocacy systems a plus. Bilingual in Spanish is a plus. Licenses, Certifications and/or

Registrations Certificates:

CLGI Certificate a plus

Licenses:

Valid NJ Driver's License a must Other Desired Skills, Abilities, and Knowledge A natural helper who is compassionate, supportive, trustworthy, resourceful, and ethical. Excellent interpersonal and relationship-building skills with clear verbal, telephonic and written communication and the ability to effectively engage individuals from diverse cultural and socio-economic backgrounds. Ability to work independently, function within an interdisciplinary team, and develop and enhance collaborations with local community agencies and organizations. Strong organizational and time-management skills with the capacity to multi-task, prioritize, problem-solve, and exercise judgement in the application of professional services. Comfortable with in-person community and home visits and outreach and ability to maintain electronic medical records.

Preferred:

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