Working within an interdisciplinary care integration team (CIT), the Community Health Worker is responsible for proactively engaging patients and serving as the linking role between a patient, their community, and their healthcare ecosystem including PCP and other specialists, and implementing targeted interventions to address barriers to health and increase access to care. 

This role requires outreach strategies to engage patients at least weekly, providing culturally appropriate health education, advocate for needs, facilitate communication between key stakeholders in the patient’s community (e.g., facilitate coordination with local food bank) and health care providers (e.g., coordinate visits, review annual wellness visits, and education materials, and engage people on the complex items healthcare stakeholders are sharing with them to help establish a question list for their next appointment and work with patients to help navigate).

Community Health Workers (CHW) coordinate care across health and social service systems serving as their patient advocate and support including yet not limited to the following:

• Needs Assessment: Assessing the health needs of a community to identify priority areas for intervention.
• Screening and Coordination: Conducting basic health screenings and help coordinate with the appropriate healthcare providers for further evaluation and treatment. 
• Outreach and Home Visits: Conducting community outreach activities, including home visits, to identify individuals and families in need of healthcare services, understand their living situation, and understand what barriers the patient is facing.
• Health Education: Providing culturally appropriate health information and education. Engage patients in material from providers / clinicians to help them understand or formulate questions for their next visit.
• Care Coordination: Facilitate communication between individuals, healthcare providers, and social service agencies to ensure seamless care coordination including facilitation of the coordination in partnership with patients virtually, in home, or on a 3-way call helping patients as needed.
• Advocacy: Advocating for individuals and communities to access necessary healthcare services, addressing barriers including transportation, language, and financial limitations. Includes assisting patients in setting services up and empowering patients/caregivers to support self-management.
• Social Support: Provide emotional support and coaching to individuals navigating complex health situations.
• Community Engagement: encourage and empower patients to build relationships with community leaders and organizations to promote health initiatives and increase community participation (e.g., attend a community center Zumba class with a patient the first time)
• Cultural Competence: Understanding and respecting the cultural differences of the community they serve to effectively communicate and provide culturally sensitive care

Duties and Responsibilities

• Develop a wholistic view of patient needs and facilitate addressing barriers to health
• Identify existing barriers to engagement with necessary resources and supports
• Provide education around maintenance of chronic health conditions, as well as available options for behavioral care and social support
• Serve as liaison between the patient and the direct care providers, assisting in navigating both internal and external systems
• Initiate care planning and subsequent action steps for high-risk members, coordinating with interdisciplinary team
• Facilitate interdisciplinary team rounds in partnership with the care team
• Supporting patients’ self-determination and motivate patients to meet health goals they have identified
• Facilitate and help patients with necessary services and supports
  • This field may include but is not limited to: assistance with transportation, food insecurity, navigation of and application for benefits including, Medicaid, HCBS, working to reduce costs associated with prescription medications, organizing schedules of follow up appointments, alleviating social isolation
• Participate in interdisciplinary review of and coordination around complex patients
• Maintain patient confidentiality in accordance with HIPAA
• Document patient encounters in medical record system in a timely manner
• Follow general policies related to fire safety, infection control and attendance
• Perform all other duties and responsibilities as required

Use your skills to make an impact

Required Qualifications

• High School Diploma or equivalent
• Minimum of 2 years of experience working in human services and navigating community-based resources
• (market dependent) Bilingual in English and Spanish or Creole with the ability to speak, read and write in both languages without limitations nor assistance

Preferred Qualifications

• Community Health Worker certification
• Bachelor’s Degree in applicable discipline
• Familiarity with state Medicaid guidelines and application processes
• Experience working with seniors’ complex needs
• Prior experience conducting home visits and knowledge of field safety practices

Skills/Abilities/Competencies Required

• Ability to multi-task in a fast-paced work environment
• Flexibility to fluidly transition and adjust in an evolving role
• Excellent organizational skills
• Advanced oral and written communication skills
• Strong interpersonal and relationship building skills
• Compassion and desire to advocate for patient needs
• Critical thinking and problem-solving capabilities