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Position: Community Health Worker

Location: HealthPoint Creekside Clinic

Salary: Based on Experience

Job Brief: Under the general guidance of the RN Care Manager, the Community Health Worker will be responsible for supporting patients in improving their comprehensive care needs. The Community Health Worker works closely and collaboratively with the Care Management team, as well as with the primary care, to ensure high quality and seamless care for patients.

Essential Functions:

• Co-Manage (with Registered Nurse oversight) a panel of patients within health center(s), working collaboratively with health center staff to engage patients into care, close gaps in care, manage referrals, coordinate preventative care, and schedule recommended appointments.
• Provide culturally competent community outreach based on available information to effectively engage patients, introduce the care management program, and support participation. Ensure patient understands program benefits, Community Health Worker's role, how to make best use of the program, and obtain consent to participate.
• Establish trusting relationships with patients to enable effective intervention and support.
• Apply motivational interviewing to conduct screening of specific conditions based on protocols such as severity of substance use, alcohol consumption or safety in order to identify appropriate referral sources for support. Identify patient strengths, needs, preferences and psychosocial/SDOH barriers to identify intervention opportunities to improved health care outcomes and quality of life.
• Support the patient in identification of actionable wellness, safety, and healthy behavior goals to optimize health outcomes in collaboration with the care team.
• Implement the patient approved plan of care in collaboration with the care team through clinical, community and home-based visits and telephonic support.
• Provide health education/information according to specified protocols addressing patient's preferred language and preference for pictorial, written, or auditory materials. Refer patients to the Registered Nurse Care Management when they require information related to their health and medical diseases.
• Promote independent patient self-management and healthy living by identifying decision-making opportunities, providing support, and referring to community support services.
• Promote effective connection of patients to a primary care provider for services. Support independent scheduling of initial and ongoing appointments, reduce barriers to attendance such as transportation or interpretation needs, and conduct follow up contact and post-visit support.
• Promote effective communication between patients and providers through skill development and pre-visit coaching. Intervene to reduce linguistic, cultural, and other barriers to health care. Encourage adherence to provider advice, treatment plan and keeping appointments. Identify and address barriers to treatment adherence according to protocol.
• Facilitate referrals according to protocols to providers and community-based organizations and programs to address identified needs and barriers to care including: housing, transportation, interpreter services, finding a physician, health insurance and benefits, labs, medication assistance, and register patients for appropriate community resources, programs and initiatives such as: Diabetes, Hypertension, Falls Prevention, Healthy Weight Management & Nutrition, Exercise, Depression/Stress, and Community & Social Services. Collaborate with community agencies to coordinate services and reduce barriers to care. Provide assistance, advocacy, and support to patients relative to making and keeping service appointments.
• Prioritize patients for program outreach utilizing available information, such reports from health plans, risk stratification, software system and data review, referrals from hospitals and providers and patient self-referral, reports, or other data.
• Provide timely feedback to referral sources.
• Assist with pre-visit information documentation and patient outreach for lab, test, and appointment reminders. Ensure barriers to appointment attendance are identified and mitigated.
• Perform basic administrative duties with high degree of accuracy including: note taking, managing team schedules, ordering supplies, arranging office set up, patient registration, reminder phone calls, writing letters, formulating emails, scheduling appointments and meetings for patients and team members, record keeping; and maintaining all forms, databases, protocols and manuals.
• Participate in interdisciplinary care team meetings as requested to share concerns/barriers and collaborate with patients and providers in developing strategies to support goal attainment.
• Document in designated software system(s) to ensure aligned view among all providers/care team members of patient progress on care plan activities and barriers to goal achievement.
• Assist with data entry and management for closing gaps of care.
• Work with Excel spreadsheets to provide concise, meaningful data back to the team.
• Attend team meetings, trainings, learning events, and other functions, as required.
• Participate in measurement of care/case management program effectiveness.
• Handle confidential information in accordance with HIPAA, state and federal privacy and confidentiality rules.
• Perform other duties as assigned.

Education Required:

• Successful completion of an accredited Medical Assistant program or meets work experience requirements for RMA certification completion
• Certification Completion as a Certified Medical Assistant or Registered Medical Assistant

Work Experience:

• Preferred: 3 years of clinical experience in a health care setting, knowledge of community resources required, and working knowledge of the provision of health care in a variety of settings

Licenses, Certificates or Registration:

• Required: CPR certification; Current Certification or Registration as Certified Medical Assistant (CMA); must possess valid state Driver's License and automobile insurance with reliable transportation.
• Preferred: CHW Certificate, Bilingual preferred

Mission: To provide evidence-based healthcare utilizing a patient empowered team approach resulting in individual wellness.

Vision: Best place for patients to receive care. Best place for providers to practice medicine. Best place for employees to work.

Values: Integrity, Respect, Empathy, Ethics, Excellence, Diversity, Safety, Professional.