Description

POSITION SUMMARY

The Community Health Worker (CHW) works closely with medical providers, primary care teams, and social services agencies to provide short term care coordination. The CHW assists with connection to resources and support to program patients to improve their health and general well-being through education and provision of coordination of care and services. Community outreach, such as home visits, health screenings and events may be required.

REPORTING RELATIONSHIPS

This position reports to the Director, Patient Centered Services & Outreach and Co-Director of Patient and Community Engagement. No other positions report to this position.

ESSENTIAL JOB DUTIES AND FUNCTIONS

While living and demonstrating our Core Values, the Community Health Worker will: Understand what it means to be the following: A Federally Qualified Healthcare Center (FQHC) A Patient Centered Medical Home (PCMH) Recognized as a National Committee for Quality Assurance (NCQA) Participant in an Accountable Care Organization (ACO) Assist patients in their homes, community, or health center setting Communicate to patients/patients the purposes of the program and the impact it may have on their wellbeing Help patients identify socio-economic issues that affect their overall health and develop health/social management plans and goals Document patient encounters and contacts made on behalf of patients in EMR; completes and submits monthly reports; maintains comprehensive electronic patient files, which include patient notes, release of information, assessments and other medical documents acquired on behalf of the patient. Educate patients on the proper use of the Emergency Department and provide information for alternatives. Coach patients in effective management of their chronic health conditions and self-care. Assists patient in understanding care plans and instructions Motivate patients/patients to be active and engaged participants in their health and overall wellbeing. Connects with Hot spotting Teams to connect patients with enabling services Provide support and advocacy during initial medical visit or when necessary to assure patients' medical needs and referrals required are being conveyed. Follow up with both patients and providers regarding health/social services plans. May be required to go to hospital as needed. Continuously expand knowledge and understanding of community resources and services Facilitate patient access to community resources, including locating housing, food, clothing, prenatal classes, parenting, and relevant mental health services. Assist patients in utilizing community services, including scheduling appointments with social services agencies and assisting with completion of applications for programs for which they may be eligible Facilitate communication and coordinate services between providers and the patients/patients. Coordinate and monitor services, including comprehensive tracking of patients' compliance in relation to care plan objectives Work collaboratively and effectively within a team. Establishes positive, supportive relationships with participants and provides feedback to other members of the team. Build and maintain positive working relationships with the patients, providers, care managers, medical residents, and office staff. Work to reduce cultural and socio-economic barriers between patients and institutions Provide self-pay patients with options to pay for services Ensure patients understand health center resources and available programs, such as Sliding fee discount program Good Faith Estimate (GFE) Outreach & Enrollment programs Language services After hours coverage Ensure compliance in the following areas: Availability and location of SDS binder Availability and location 990 binders for all TWC entities Understanding role and responsibilities in an emergency to help coworkers and patients to safety Demonstrate positive working relations with patients, visitors, and staff to effectively communicate The Wright Center's mission Attend weekly huddles and morning/afternoon mini huddles Participation in rotation of extended access hours including late nights, weekends and holidays Cross coverage of other locations and service lines for continued support and access for patients Understanding of multiple insurance dynamics including copays, coverage, navigation Obtain and maintain the Pennie Assister training certification to outreach and enroll patient in the appropriate insurance within 90 days of employment Commitment of outreach and engaging patients with positive PCRT screenings and outstanding barriers to care Play key role of capturing patient demographic information needed, especially barriers to care to help provide overall picture of patient population Perform miscellaneous job-related duties as assigned Requirements Meet The Wright Center for Community Health and its affiliated entity The Wright Center for Graduate Medical Education EOS© People Analyzer Tool Buy in and experience working in the EOS® model (strongly preferred) Mission-oriented; represents the enterprise in a professional manner while demonstrating organizational pride High school diploma or GED; at least 3 years of experience directly related to the duties and responsibilities specified Current BLS certification Completed degree(s) from an accredited institution preferred Complete AHEC training for CHW certification within one year of employment Must apply for the CCHW PA certificate after completing the CHW training and within thirteen (13) months of hire, must obtain the certificate within 15 months from the date of hire Bilingual highly desired Strong interpersonal and communication skills and the ability to work effectively with a wide range of constituencies in a diverse community Knowledge of community agencies and resources Working knowledge of patient centered medical home model and multi-system outreach programs related to health care delivery, clinical education, and health-related services Ability to plan, implement, and evaluate individual patient care plans Knowledge of transportation and other barriers to care that may be encountered by patient Ability to communicate medical information to health care professionals and care coordinators over the telephone Basic computer skills Skill in organizing resources and establishing priorities Creative and analytical thinking