Job Details
The CRC Community Health Worker (CHW) will assist patients with complex medical, social, and/or behavioral health needs by accessing community-based resources, and fully utilizing personal/community support systems, to improve life circumstances leading to better health outcomes.
The CRC Community Health Worker (CHW) will assist patients with complex medical, social, and/or behavioral health needs by accessing community-based resources, and fully utilizing personal/community support systems, to improve life circumstances leading to better health outcomes.
Community Health Workers (CHWs) play a critical role in improving the health and well-being of patients, particularly high-risk chronically ill managed care Members by using their knowledge of patients communities and common lived experiences. Armed with healthcare training that prioritizes prevention and patient-empowered self-management, along with high levels of compassion and strong interpersonal skills; CHWs help patients better navigate medical, behavioral health, and social service systems to meet their needs.
The CRC Community Health Worker (CHW) will assist patients with complex medical, social, and/or behavioral health needs by accessing community-based resources, and fully utilizing personal/community support systems, to improve life circumstances leading to better health outcomes.
The CHW will provide care coordination services and serve as an integral part of the care management team, collaborating directly with primary care offices, care management, social work, specialists, and others.
The CHW will work in the community in a variety of settings, including patient homes, medical offices, inpatient facilities (such as hospitals and EDs), community-based organizations, public facilities, homeless shelters, and more. The CHW will: advocate for patients; empower patients to become effective advocates for their own needs and the needs of their families; identify and support patients overcoming obstacles related to treatment plans and other medical, social, and/or behavioral health services; help patients secure necessary and appropriate medical, social, and/or behavioral health services.
The CHW is responsible, along with other members of the Medical Management Team, for contributing to the clinical, quality, financial, and patient satisfaction outcomes.
- Acts as a peer support for enrolled patients, building relationships with individuals and their families as well as advocating for patients as they navigate the health care system.
- Assist members in identifying their goals (health, behavioral, social, etc.) and provide assistance and support in achieving those goals.
- Attends and contributes to Team Conferences regarding care to/for specific patients.
- Coordinates with care management and other members of interdisciplinary team to report on patient progress and confer if interventions require modification.
- Engages with patients and families across care settings such as the transition from hospital to home.
- Assists the patient in addressing the following:
Health-Related Social Needs/ Social Determinants of Health
- HRSN/SDOH Include: housing insecurity/homelessness, substandard housing conditions, food/nutrition, transportation, utilities, exposure to violence, social isolation, language/ communication barriers, cultural isolation, parenting/educational skills, elder care, parent-child conflict, family relations issues, recreational activities, and more.
- Health, Behavioral Health, Substance Use:
- Includes: assisting with medical appointments (scheduling, confirmation, reminders, transportation, follow-up), effective engagement with primary care, medical assistance, insurance enhancements, prescriptions, medical equipment, dental care, chronic condition management including health education/prevention, barriers to treatment-plan-compliance including medication adherence, facilitating services to address BH/SUD needs of patient and/or family members across all levels of need (mild/moderate/severe) from treatment to recovery.
- Regarding the above, relays relevant information to Care Management and Primary Care providers to improve future patient experience.
- Assists in completing applications, forms, and acquiring additional documentation as required. Reviews and verifies the accuracy of required paperwork. Works under the direction of the Clinical Leadership including: Medical Director, Director of Care Management and Licensed Clinical Social Worker, in coordination with CRC management, hospital care management, hospital social work, Primary Care Physician (PCP) staff, Behavioral Health, and other care coordination staff to determine plan-of-care management, coordinate and complete care plan-related activities, and meet the medical, social, and/or behavioral health needs of attributed patients.
- Attends relevant training as necessary to maintain professional certification and/or knowledge
- Other duties as assigned within the scope of position expectations.
Education/Experience:
Required: High School Diploma or equivalent
Knowledge/Skills/Abilities:
- Possess the strong interpersonal skills required to build trusting, supportive, effective relationships with patients. This includes high levels of empathy, respect for patients/families, genuineness, acceptance, and concern for well-being.
- Courteous, cordial, cooperative, and professional interaction with diverse groups of co-workers, external business partners and the community.
- Willingness to make face-to-face visits independently with patients in a variety of settings: patient home, provider office, Skilled Nursing Facility, etc.
- Ability to travel to multiple locations; valid driver s license and dependable automobile that is insured.
- Extensive familiarity with available community resources throughout the state to meet the needs of Medicaid patients enrolled in the CRC risk-based Medicaid health plans.
- Computer literate: proficient with Microsoft Suite including but not limited to Teams, Word, Excel, Power Point, Care Management software and web-based applications.
- Strong written and verbal communication.
- Highly organized and able to work independently as well as collaboratively .
- Trustworthy